Examining Constructs of the Health Belief Model As Predictors of Haitian Men's Intention Regarding Prostate Cancer Screening D

Home , Health belief model

EXAMINING CONSTRUCTS OF THE HEALTH BELIEF MODEL AS PREDICTORS

OF HAITIAN MEN’S INTENTION REGARDING PROSTATE CANCER

SCREENING

DISSERTATION

Presented in Partial Fulfillment of the

Requirements for the Degree of

Doctor of Philosophy in Nursing

Barry University

Jhonii Price Louis, II

2016

EXAMINING CONSTRUCTS OF THE HEALTH BELIEF MODEL AS PREDICTORS

OF HAITIAN MEN’S INTENTION REGARDING PROSTATE CANCER

SCREENING

Jhonii Price Louis, II

2016

APPROVED BY:

______Ferrona A. Beason, PhD, ARNP Chairperson, Dissertation Committee

______Claudette R. Chin, PhD, ARNP Member, Dissertation Committee

______Jessie M. Colin, PhD, RN, FRE, FAAN Member, Dissertation Committee Program Director, College of Nursing and Health Sciences

______John McFadden, PhD, CRNA Dean, College of Nursing and Health Sciences

Abstract

Background: The most recent report of Global Burden of Cancer (GLOBOCAN) indicated the incidence rate of prostate cancer in Haiti as 38.6 and the mortality rate as

32.3 per 100,000. The literature supports a high correlation between early prostate cancer screening and low mortality rate from the disease. Yet, the participation of Haitian men in prostate cancer screening remains low (Kleier, 2010). The literature has a lack of research on this matter, which presented the gap to be examined.

Purpose: The purpose of this study was to determine which of these selected constructs of the Health Belief Model (perceived susceptibility, perceived benefits, and perceived barriers) are predictors to the intention of Haitian men regarding prostate cancer screening. Other modifying variables were also considered as predictors to the outcome variable.

Theoretical Framework: The Health Belief Model (HBM) was utilized as the primary guide for the study; the Purnell Model for Cultural Competence served a complementary lens to account for any cultural gap studying this population.

Method: A correlational, predictive cross-section design was used to obtain a convenience sample in Haiti (N = 200). The Champion HBM scale was adapted and modified for prostate cancer; it was administered in Haitian Creole and French. Data were analyzed through descriptive, correlation, logistic regression, and the nonparametric

Kruskal-Wallis ( H) analysis of variance (ANOVA) to determine predictive correlation among the variables.

Results: Seven hypotheses were tested; all but one was supported. Perceived benefits were found to have a predictive relationship to Haitian men’s intent to screen for prostate

cancer [ c 2 (3) = 14.47, p = .00 ]. Further, the nonsignificant Hosmer and Lemeshow statistic, c 2 (8) = 4.33, p = .83 supports that the data was a good fit for the model. No other variable was found to be significant.

Conclusion: The findings from this study can be utilized by nurses and other healthcare professionals to generate and implement culturally appropriate interventions; consequently, these interventions will decrease the morbidity and mortality rates of prostate cancer among Haitian men in Haiti and abroad.

ACKNOWLEDGMENTS

“Béni soit l'Eternel! ” Blessed be the Almighty God for taking charge and bringing along a superb team to guide me throughout this process. Such a journey can be taxing and fearful. It can interject doubts into one’s mind regarding one’s own ability, for it is a long and strenuous journey. However, I have remembered: 2 Timothy 1:7 “For

God has not given us a spirit of fear but of power, of love and of a sound mind” and

Philippians 4:13 “ I can do all things through Him who strengthens me.” These quotes have become my dictum during this journey and will remain so for the rest of my life.

Besides the Almighty Father, I will be evermore grateful for the persistent unaltered support and love from my family, Shiin M. Louis and Claire S. Louis. Your patience and understanding have facilitated my will to go through this journey and pursue success. I thank you very much. I must also acknowledge every member of my extended family for their tolerance of my lack of presence in the family affairs during this journey.

You have allowed me to fully focus on this member of the family: Me. Thank you.

I will be eternally indebted to the “Dream Team”: My committee chair, Dr.

Ferrona A. Beason for your leadership, guidance, and understanding; my committee members, Dr. Claudette R. Chin for being a mentor, and for your dedication and genuine interest in my work; and Dr. Jessie M. Colin for literally everything. You have given me the foundation to go through this process. To me personally, you have held many roles during this journey. I thank you for your expertise. I must also extend my gratitude toward Dr. JoAnn Kleier for being a pioneer on this particular topic concerning this population and for agreeing to come on board to help with the statistics of this study.

To the founders of UPH, Mr. Serge B. and Mrs. Sandra Montes, I am particularly beholden to you. You have facilitated a task that others would consider impossible. You placed all your resources and your staff at my disposition and made my data collection seem stress free. In addition, I must certainly mention Mr. Johnson Jean-Louis, whom I call the manager. Thank you for toting me around the country. Your assistance was very much essential and appreciated.

A world of thanks to the Rev. Pere Castel Germeil, the Academic Council

President, and the entire staff of L’ Universite Polyvalente d’ Haiti (UPH). All was possible because of the collaboration of UPH. The UPH staff from Les Cayes deserves this special recognition for their hard work. Special thanks is extended to Mr. Viviens

Andre Marc, Site Coordinator, Rev. Michel Emeste, Brother Charles Jouvenel, and

Brother Alain Gaspard. Your service was beyond my expectation.

Certainly, any long and laborious journey is psychologically demanding. A journey such as this definitely requires perpetual support. To Ms. Z. Pricelle George, you have been this constant from the very commencement. You have earned every praise or credit that is due to you. I am sincerely thankful to you for who you are and all that you do. That is what true family does!

Although I felt alone several times on this journey, I must also acknowledge the wonderful fellow Miami cohort with whom I took this journey. They both directly and indirectly strengthened me along the way, letting me know that we all have flaws and the journey does not have to be perfect. Most importantly, they taught me that the journey does not have to be time limited or restricted. The essential goal is to arrive at the destination strong and proud. That was exactly my intention—STRONG and PROUD.

vii

Finally, I am sincerely thankful to my friend Roger Edouard for linking me to Dr.

Jean A. Francois for his translation service. I thank you Dr. Francois; I was exceptionally gratified with your service. To anyone else not mentioned but played a role in helping me with this accomplishment, I sincerely thank you. Your contribution was surely valuable and appreciated. Let us all celebrate this end result.

“Being confident of this very thing, that He who began a good work in you will carry it unto completion….” Philippians 1:6

viii

DEDICATION

“The lives of those who pass away remain in the memory of those who live and love them.” This dissertation is first dedicated to my beautiful daughter, Khonii S. Louis, who left us too soon on 10/10/2010. You were and still are known to us as the love butterfly. Your philosophy of loving everyone was plain and simple. It only dictates that the world does not have to be so complicated because “Love endures it all.” Thank you for loving me unconditionally. Regardless of my flaws, you just wanted me to be your papa. Thank you. With your spirit, I shall continue to soar high.

“Anyone who has given love will always live in another’s heart.” This dissertation is also dedicated to my dear mother, Lamercie Louis, another beautiful soul who left us too soon. You laid such a strong foundation; the result is apparent via the lives of your children. I thank you for giving me so much love until the end. Most importantly, you have taught me that “Hard work is real and working hard is freedom.”

This is for you, mom. This dedication is also extended to my father, Anthony Louis.

You have shown me repeatedly that a man must work hard in order to provide for his family. I used to wonder if it was ethical for men to take breaks. Your work ethic surely influenced my perception about life in general. I am sure this accomplishment of mine makes you proud. Thank you for being such a rock in my life; thank you for being there.

Finally, this dissertation is dedicated to my entire family. As much as we are part of each other, my success is surely yours. In conclusion, this is dedicated to all Haitian men everywhere. This work was completed with you in mind. Special dedication goes out to all the participants of this study. Your input was key to the result of this work.

Hence, this work would not be possible without you. THANK YOU!

TABLE OF CONTENTS

TITLE PAGE………………………………………………………………………………i

SIGNATURE PAGE……………………………………………………………………...ii

Abstract ...... iv

ACKNOWLEDGMENTS ...... vi

DEDICATION ...... ix

TABLE OF CONTENTS ...... x

LIST OF TABLES……………………………………………………………………….xv

LIST OF FIGURES ...... xvi

CHAPTER ONE ...... 1

Background of the Study ...... 2

Historical Context ...... 2 Prostate Gland ...... 3 Prostate Cancer ...... 4 Global Concerns of Prostate Cancer...... 6 Prostate Cancer in the United States ...... 9 Prostate Cancer in the Caribbean ...... 11 Prostate Cancer in Haiti ...... 13 Problem Statement ...... 16

Purpose Statement ...... 16

Theoretical and Operational Definitions of Key Terms ...... 17

Perceived Susceptibility ...... 17 Perceived Benefits ...... 17 Perceived Barriers ...... 18 Intention ...... 19 Research Questions and Hypotheses ...... 19

Research Question and Hypothesis One ...... 20 Research Question and Hypothesis Two ...... 20 Research Question and Hypothesis Three ...... 20 Research Question and Hypothesis Four ...... 20 x

Research Question and Hypothesis Five ...... 21 Research Question and Hypothesis Six ...... 21 Research Question and Hypothesis Seven ...... 21 Theoretical Framework ...... 21

Positivism ...... 22 The Health Belief Model ...... 23

Perceived Susceptibility ...... 25 Perceived Severity ...... 25 Perceived Benefits ...... 25 Perceived Barriers ...... 26 Cues to Action ...... 26 Self-Efficacy ...... 27 The Notion of Perceived Threat ...... 27 Relationship of HBM to the Study ...... 30

The Purnell Model for Cultural Competence ...... 32

Assumptions ...... 34

Theoretical Assumptions ...... 34 Researcher Assumptions ...... 35 Significance of the Study ...... 36

Significance of the Study to Nursing ...... 36

Implications for Nursing Education ...... 37 Implications for Nursing Practice ...... 37 Implications for Nursing Research ...... 38 Implications for Health/Public Policy ...... 39 Scope and Limitations of the Study ...... 39

Threats to External and Internal Validity ...... 41

Threats to External Validity ...... 41 Threats to Internal Validity ...... 42 Chapter Summary ...... 42

CHAPTER TWO Literature Review ...... 44

Studies Using the Health Belief Model as a Framework ...... 45

Factors Influencing Healthcare Seeking Behaviors ...... 59

Factors Influencing Prostate Cancer Screening Behavior ...... 68

Prostate Cancer Research Focused on Caribbean-Born Men...... 80

Chapter Summary ...... 93

CHAPTER THREE Methods ...... 95

Overview of the Design...... 96

Quantitative Inquiry...... 96 Descriptive Correlational and Cross-Sectional Design ...... 97 Research Questions and Hypotheses ...... 99

Setting...... 100

Sample ...... 101

Projected Sample Size ...... 102 Sample Size by Power Analysis ...... 103 Inclusion Criteria ...... 104

Exclusion Criteria ...... 104

Ethical Considerations...... 105

Access and Recruitment Procedures ...... 107

Data Collection Procedure ...... 108

Instruments/Measures...... 110

Demographic Questionnaire ...... 111 The Champion Health Belief Model Scale ...... 112 Reliability ...... 115 Validity ...... 116 Scoring of the Instrument ...... 118 Data Analysis Plan ...... 118

Data Cleaning and Storage ...... 118 Analysis of Data ...... 119 Chapter Summary ...... 119

CHAPTER FOUR Findings of the Study ...... 121

Characteristics of the Sample ...... 122

Results of Psychometric Estimations ...... 124

Exploring the Data ...... 124 xii

Descriptive Values for the Scores on the Scales...... 125 Reliability as Internal Consistency...... 125 Distribution of Scores ...... 126 Testing for the Assumption of Independence of Independent Variables ...... 129 Hypothesis Testing ...... 129 Restatement of Research Questions and Hypotheses ...... 131

Hypothesis 1 ...... 131 Hypothesis 2 ...... 132 Hypothesis 3 ...... 133 Hypotheses 4, 5, 6, and 7 ...... 134 Chapter Summary ...... 135

CHAPTER FIVE Summary and Discussion...... 137

Summary of the Study ...... 138

Summary and Discussion of the Findings ...... 144

Demographic and Background Characteristics ...... 144 Relationship Between Major Study Variables ...... 149 Significance of the Study ...... 157

Significance of the Study to Nursing ...... 158

Implications for Nursing Education ...... 160 Implications for Nursing Practice ...... 161 Implications for Nursing Research ...... 163 Implications for Health/Public Policy ...... 165 Strengths and Limitations of the Study ...... 167

Strengths ...... 168 Limitations ...... 169 Recommendations for Future Study ...... 170

Conclusion ...... 173

REFERENCES ...... 176

APPENDIX A BARRY UNIVERSITY APPROVAL LETTER FROM BARRY UNIVERSITY’S INSTITUTIONAL REVIEW BOARD ...... 195

APPENDIX B BARRY UNIVERSITY PARTICIPANT INTRODUCTORY AND COVER LETTER ...... 198

APPENDIX C BARRY UNIVERSITY LETTER TO ADMINISTRATORS OF COMMUNITY ESTABLISHMENTS ...... 203 xiii

APPENDIX D BARRY UNIVERSITY LETTERS OF PERMISSION FROM ADMINISTRATORS OF COMMUNITY ESTABLISHMENTS ...... 207

APPENDIX E BARRY UNIVERSITY FLYER FOR RECRUITING PARTICIPANTS ...... 209

APPENDIX F PERMISSION TO USE CHBMS ...... 215

APPENDIX G DEMOGRAPHIC QUESTIONNAIRE ...... 217

APPENDIX H CHAMPION’S HEALTH BELIEF MODEL SCALES (CHBMS) MODIFIED FOR PROSTATE CANCER ...... 224

APPENDIX I LETTER FROM TRANSLATOR ...... 234

APPENDIX J RESEARCH QUESTIONS AND HYPOTHESES DATA SHEET ...... 236

VITA ...... 238

xiv

LIST OF TABLES

Table 1 Parameters of Pre- and Posttest, Paired t-Test (Carter et al., 2010, p. 102) .... 75

Table 2 Characteristics of the Sample (N = 200) ...... 123

Table 3 Descriptive for the Predictor and Outcome Variables (N = 200) ...... 125

Table 4 Summary of Reliability Values for the Scales (N = 200) ...... 126

Table 5 Logistic Regression Predicting Intent to be Screened for Prostate Cancer from the Theoretical Predictor Variables (N = 200) ...... 132

Table 6 Logistic Regression Predicing Intent to be Screened for Prostate Cancer from Age (N = 200) ...... 134

Table 7 Summary of Results of Hypothesis Testing Using Kruskal-Wallis Nonparametric One-Way ANOVA ...... 134

LIST OF FIGURES

Figure 1. Prostate gland and surrounding organs (Knott, 2014)...... 3

Figure 2. Location of Haiti in the Caribbean (World Atlas, n.d.)...... 12

Figure 3. Haiti's states and capital (University of Texas, 1999)...... 14

Figure 4. The standard schema of the health belief model...... 28

Figure 5. Louis' (2016) adaptation of the health belief model for application to prostate cancer screening...... 30

Figure 6. The Purnell (2013) model for cultural competence...... 33

Figure 7. Frequency histogram with normal curve superimposed on scores for intent to be screened for prostate cancer...... 127

Figure 8. Bar chart of scores for outcome variable, intent to be screened for prostate cancer, recoded into dichotomous, categorical level data...... 128

xvi

CHAPTER ONE

In the face of continuing progress that has taken place in the United States of

America from the past few decades to present, African Americans continue to lag far behind their White counterparts. Such a gap does not only exist in economical, occupational, and political status; it also exists in relation to health status (Smedley,

Stich, & Nelson, 2002). The data are even more apparent with regards to African

American men, who continue to have the lowest life expectancy and the highest mortality rate as compared with men of other racial and ethnic groups in this country (World Life

Expectancy, n.d.).

The Office of Disease Prevention and Health of the Centers for Disease Control and Prevention indicates that malignant neoplasm is second to heart disease at a rate of

172.3 per 100, 000 in the population on the top-ten list of causes of death among African

American men (Centers for Disease Control and Prevention [CDC], 2011). However, early detection of cancer such as prostate cancer through the use of screening tools such as prostate specific antigen (PSA) test and digital rectal exam (DRE) is a key factor to increasing survival rate (American Cancer Society [ACS], 2007). This statement can also be applied to Haitian-American men in the United States because they are often categorized as part of the African-American community (U.S. Census Bureau, 2012).

Moreover, this phenomenon does not apply only to Haitian-American men in the United

States; it also applies to Haitian men in Haiti. Therefore, it is important to investigate the intention of Haitian men living in Haiti regarding prostate cancer screening considering the most recent world cancer report (GLOBOCAN, 2012). 2

Background of the Study

Historical Context

The prostate gland was first described in 1536 by Niccolo Massa, a Venetian anatomist, and illustrated by a Flemish anatomist, Andreas Vesalius in 1538. However, it was actually identified in 1853 (Adams, 1853). Prostate cancer was considered to be a very rare disease in the 19th century, partly because of short life expectancy and poorer methods of detecting it. Hence, the disease would usually be detected in its late phase explaining why surgeries were the very first treatment for prostate cancer (Lytton, 2001).

Prostatectomy, the removal of the entire gland, was first performed in 1904 by Hugh H.

Young at Johns Hopkins Hospital (Young, 1905). By the middle of the 20th century,

Transurethral Resection of the Prostate (TURP) was developed and replaced radical prostatectomy for symptomatic relief of urinary obstruction. Another procedure developed in 1983 by Patrick Walsh was the radical retropubic prostatectomy (Denmeade

& Isaacs, 2002). This surgical approach was very progressive given the level of its achievement. It made possible the removal of the prostate gland and lymph nodes while maintaining the penile function.

Beside the path of surgery, other forms of treatment were in progress. In 1941,

Charles B. Higgins, a physician, published studies in which he used estrogen to oppose testosterone production in men with metastatic prostate cancer. The discovery of this treatment called chemical castration won him the 1966 Nobel Prize in physiology or medicine (Higgins & Hodges, 1941). In addition, the work of Andrzej W. Schally and

Roger Guillemin on hormones was able to determine the role of the gonadotropin- releasing hormone (GnRH) in reproduction. In turn, GnRH receptor agonists such as

3 leuprolide and goserelin were developed and used to treat prostate cancer. They also won the Nobel Prize in Physiology or Medicine in 1977 (Schally, Kastin, & Arimura, 1971).

Other prostate cancer treatments that emerged in the 20th century were radiation therapy and chemotherapy. Cyclophosphamide and 5-fluoroucil were among the initial regimen but quickly joined by many systemic chemotherapy drugs (Scott et al., 1975).

However, treatment effectiveness continues to have correlation with early detection.

Figure 1. Prostate gland and surrounding organs (Knott, 2014).

Prostate Gland

The prostate gland is only found in the male reproductive system. The prostate is a walnut-sized gland located between the bladder and the penis. The prostate is just in front of the rectum. The urethra runs through the center of the prostate, from the bladder to the penis, letting urine flow out of the body. The prostate secretes fluid that nourishes and protects sperm. During ejaculation, the prostate squeezes this fluid into the urethra to

4 be expelled with sperm as semen (National Cancer Institute at The National Institutes of

Health, n.d.).

The size of the prostate gland changes overtime with age. A growth spurt occurs during puberty, driven by the rise in male hormones (called androgens) in the body, such as testosterone and dihydrotestosterone (DHT). The prostate gland is responsible for producing some of the fluid that protects and nourishes sperm cells in semen, making the semen more liquid (American Cancer Society, n.d.). The prostate gland usually grows very slowly in adult men. It remains approximately about the size of a walnut. However, it can become much larger in older men, which can become problematic.

Prostate Cancer

According to the National Cancer Institute (n.d.), prostate cancer is defined as a cancer that forms in tissues of the prostate gland. The prostate gland is composed of different types of cell, but almost all prostate cancers develop from the gland cells. They are the cells that produce the prostate fluid that is added to the semen (American Cancer

Society, n.d.). The cancer that starts in gland cells is medically known as adenocarcinoma. The exact cause of prostate cancer is unclear. However, it is usually derived from an abnormality in which a cell consequently gives birth to a malignant cancerous tumor in the prostate gland. Some abnormal genes within the cell may cause the cell to multiply. Unlike many other cancers, prostate cancer can be constrained in a small region and never expand to cause any harm (Kenny, Tidy, & Cox, 2014). Prostate cancer usually occurs in older men, making aging the primary risk factor for prostate cancer. Other risk factors include family history, diet, and ethnicity. A diet that is high in fat and low in fruits and vegetables may pose a risk. Regarding ethnicity, Afro-

Caribbean men rank at the top for having prostate cancer, whereas Asian men rank at the very bottom (GLOBOCAN, 2012; Kenny et al., 2014).

The symptoms of prostate cancer usually occur at a late stage due to the slow growth of this type of cancer. The symptoms may manifest as: poor stream , which increases the time of urination; hesitancy , which delays the start of urine flow; dribbling , which may cause a trickle effect after finishing up at the toilet; frequency , which causes the passing of urine more frequently; urgency , which may cause the need to go quickly; and poor emptying , which causes the feeling of a bladder not quite empty (Kenny et al.,

2014). All of these symptoms usually occur with the enlargement of the prostate consequently in older in men. Moreover, they may also occur with a non-cancerous benign enlargement of the prostate. The medical term for this condition is benign prostatic hyperplasia (BPH).

Unlike other type of cancers, prostate cancer is known to have a very high survival rate. However, early screening for and detection of prostate cancer is highly attributed to the high survival rate. There are two common ways to screen for prostate cancer: the PSA test and the DRE. The PSA test measures the level of PSA in the blood.

PSA is a substance made by the prostate. The levels of PSA in the blood tend to be higher in men who have prostate cancer. However, the PSA level may also be elevated in other conditions that affect the prostate (CDC, 2013). The DRE is the palpation of the prostate gland through digital manipulation via the rectum (Baker, 2009). It is performed by a health care practitioner inserting a gloved, lubricated finger into the rectum to examine the posterior surface of the prostate gland, estimate the size, shape, and consistency of the prostate and feel for lumps and nodules or other abnormalities (CDC,

2013). When either of these two screening tools is positive for prostate cancer, a biopsy is usually ordered for further confirmation. A biopsy is a procedure where a small sample of tissue is removed from a part of the body, then studied under the microscope to look for abnormality (Kenny et al., 2014).

Currently, a wide variety of treatments for prostate cancer exist. These treatments are being mentioned irrespective of their effectiveness and are not limited to all other treatments that may be available. The treatments include active surveillance, hormone treatment, surgery, radiotherapy, and chemotherapy. In general, the prognosis is usually good, especially for men with early stage of prostate cancer.

Global Concerns of Prostate Cancer

Many forms of cancer affect the lives of men gravely around the world. Among them, prostate cancer is one of the top five cancers posing a threat to the lives of men worldwide. Prostate cancer is currently classified as the fourth most common type of cancer and the second most common cancer in men, yielding only to lung cancer

(GLOBOCAN, 2012). The division for global cancer research of the World Health

Organization (WHO) reported that an estimated 1.1 million men were diagnosed with prostate cancer in 2012. That estimate accounted for 15% of all the cancers diagnosed in men, with almost 70% of the cases arising from the more developed countries

(GLOBOCAN, 2012). The high percentage of occurrence in the more developed countries may be due to a variety of factors. One factor may be their access to tools and science for detecting prostate cancer. Another factor may be the fact that men in those countries have better access to health care. Consequently, that argument can expand further with many other factors such culture, wealth, education, religion, etc.

The incidence rates of prostate cancer around the world vary in many folds. The highest rates are reported from Australia, New Zealand, and North America. The rates range between 111.6 and 97.2 per 100,000 persons of the population, respectively(GLOBOCAN, 2012). The high occurrence is also reported from Western and Northern Europe due to their widespread practice of performing the PSA test and subsequent biopsy. Other regions with high occurrences that are considered to be less developed are the Caribbean (79.8), Southern Africa (61.8), and South America (60.1).

The regions with the low occurrences are concentrated within the parameter of Asia,

Northern, Eastern, and Western Africa. Asian men have the lowest rate of prostate cancer. However, geographic location seems to affect the statistics. The rate of prostate cancer among Chinese men living in the United States is reported to be 15 times higher than their counterparts in China (Lee et al., 2003).

The mortality rates of prostate cancer around the world also vary in many folds.

The proportion of incidences that occur does not seem to have a parallel correlation with the proportion of mortality. For example, in 2012, the United States had 233 cases and 30 deaths as compared to India, which had 19 cases and 12 deaths. In other words, 63% of

India’s cases resulted into mortality as compared to 12.8% of the cases in the United

States. Despite the high incidence rates in the more developed countries, their mortality rates are extremely lower as compared to the less developed countries. Prostate cancer is the fifth leading cause of death from cancer in men. An estimated 307,000 deaths occurred in 2012 (GLOBOCAN, 2012). The mortality rates are predominantly high in

Black populations, with the Caribbean at 29 and sub-Saharan Africa at 19-24 per 100,000 persons of the population. The lowest mortality rates are found within the continent of

Asia at 2.9 per 100,000 persons of the population. The high mortality rates in the less developed countries are certainly influenced by many factors. One obvious factor could be the lack of healthcare access for men living in these countries (GLOBOCAN, 2012); and the list can be expanded continuously. Prostate cancer is a major threat to men’s health around the world, especially in those less developed countries.

Education for early screening seems to be the trend in most countries with a decrease of mortality for prostate cancer. Although there has been an increase in incidence rate in Europe in general, the mortality rate seems to have decreased significantly. The highest prostate cancer mortality rates can be found in the Baltic region

(Estonia, Latvia and Lithuania) and in Denmark, Norway, and Sweden (Bray, Lortet-

Tieulent, Ferlay, Forman, & Auvinen, 2010). In contrast, there has been a uniform decrease in prostate cancer mortality in 13 of 37 European countries considered predominantly to be high-resource countries; some examples of those countries are

England, Wales, Hungary, France and the Czech Republic (Bray et al., 2010). The decreasing prostate cancer mortality rates may be attributable to improvements in treatment and to an effect of prostate specific antigen (PSA) testing (Bray et al., 2010).

However, the increasing mortality rate in the Baltic region indicates the need for further monitoring.

In Canada, early screening is encouraged for men who fit the more at-risk category. The primary risk factor is age, older than 44. In addition to age, family history and ethnicity play a major role regarding who should be screened for prostate cancer.

The treatments seem to follow the general recommendations, which include active

9 surveillance, hormone therapy, surgery, radiotherapy, and chemotherapy (Canadian

Cancer Society, n.d.).

The Africa Cancer Foundation is a non-profit organization with a vision of

“cancer-free Africa.” This organization posts on its website that it champions and believes in early detection to reduce cancer mortality rates. For that matter, they collaborate with many health institutions to provide free cancer screening and consultations. In general, they believe that a more empowered people will seek screening early and make informed decisions as they remain actively engaged with their healthcare professional (Africa Cancer Foundation, n.d.).

In the Pan-American region, prostate cancer is being handled mainly through the recommendations of the Pan American Health Organization (PAHO), an international health agency that serves as the World Health Organization’s regional office for the

Americas (Pan American Health Organization [PAHO], n.d.). The region also benefits from many health authority agencies in the United States, such as the Centers for Disease

Control and Prevention, the National Institutes of Health (NIH), and the American

Cancer Society (ACS). Screening for early detection is paramount in the battle against any type of cancer. Therefore, education addressing early screening has been one of the primary methods to fight against cancer. As for prostate cancer, treatments vary based on the diagnosed cases and available resources of each country.

Prostate Cancer in the United States

Prostate cancer is the most common type of cancer and the second leading cause of cancer death in men in the Americas (GLOBOCAN, 2012). The statistics reported in the 2012 global research on cancer are increasingly overwhelming. More than 412,000

10 new cases and 85,000 deaths are reported annually in the Americas (Pan American

Health Organization, n.d.). The United States is one of the countries with the highest incidence in the Americas but maintains the lowest mortality rate along with Canada.

Annually, there is an estimate of 233,000 new cases and 29,480 deaths from prostate cancer in the United States (National Cancer Institute at The National Institutes of Health, n.d.). Prostate cancer is the seventh leading cause of death among men aged 65 and older as compared to coronary heart disease and lung cancer as number one and two, respectively. The survival rate of American men is exceptionally high. A 15-year survival rate is at 94% (American Cancer Society, n.d.).

Such a success with prostate cancer health is undoubtedly due to the access of high quality of healthcare in collaboration with the progressive health science that the

United States possesses. Moreover, the success may also be explained with the associations of the many opportunities (i.e., ranging from education to wealth) that men living in the United States may have (GLOBOCAN, 2012). The CDC maintains the DRE and the PSA tests as the two main screening tools for prostate cancer. However, after a new report from the United States Preventive Services Task Force (USPSTF) endorsed a grade “D” to the PSA test, the CDC warns healthcare practitioners to take a more comprehensive approach (CDC, 2013). The USPSTF found that the test carries very little benefit versus the potential harm that comes along with it. Essentially, the CDC recommends that practitioners fully inform patients of their screening options, considering age, family history, and ethnicity (CDC, 2013).

Treatments for prostate cancer vary in the United States. They are similar with the recommendations from around the world in addition to a few more approaches such

11 as cryotherapy , which entails the introduction of a special probe inside or near the prostate cancer to freeze and kill the cancer cells; biological therapy, which utilizes the body’s immune system to help it fight cancer or to control side effects from other cancer treatments; and high-intensity focused ultrasound, which involves directing high-energy sound waves (ultrasound) at the cancer to kill cancer cells (CDC, 2013). In addition, proton therapy , a fairly new treatment, was found to be highly effective. Proton therapy treats prostate cancer with high doses of protons that are more accurate, and potentially more effective, than traditional radiation (UF Health, 2015). The University of Florida

Health Proton Institute conducted a recent study with men 60 and younger treated with proton therapy for prostate cancer. The findings reported high satisfaction for quality of life indicators such as sexual and urinary function (UF Health, 2015).

Prostate Cancer in the Caribbean

The Caribbean is one of the regions in the Americas with both the highest incidence and mortality rates for prostate cancer. This fact is well correlated with the high incidence and high mortality reported in the Black population. In the world ranking of cause of death from prostate cancer, the top ten primarily consists of countries of the

Caribbean, with the exception of Seychelles (a country located in the southeastern coast of Africa, which consists of a group of 115 small islands). The mortality rates from prostate cancer for the world ranking are calculated per 100,000 persons of the population. The top ten countries are ranked respectively with their rates as follows:

Dominica at 46.8, Saint Kitts at 31.4, Barbados at 27.8, Seychelles at 27.4,

Antigua/Barbuda at 24.8, Grenada at 24.3, Saint Lucia at 23.7, Saint Vincent at 23.2,

Trinidad/Tobago at 22.6, and Haiti at 21.0 (World Life Expectancy, n.d.). Other

Caribbean countries not in the top ten are Dominican Republic ranked 11th at a rate of

18.9; Bahamas ranked 13th at a rate of 17.7; Cuba ranked 16th at a rate of 15.8; and

Jamaica ranked 28th at a rate of 11.3.

The World Health Organization envisages that the number of new cases and deaths from prostate cancer will double by 2030 if the current trend continues

(GLOBOCAN, 2012). It is estimated that new cases may reach more than 250,000 with

100,000 deaths by 2030. Prostate cancer is unquestionably a burden for the Caribbean, given the fact that most of the countries in the Caribbean are underdeveloped. The statistics support that countries with the highest Gross Domestic Product per capita

(GDP) have the highest incidence/mortality ratios for prostate cancer (GLOBOCAN,

2012). For example, the United States may have one death for every nine new cases as compared to Haiti with one death for every two new cases of prostate cancer. Evidently, this speaks to the extreme lack of resources experienced by Haiti.

Figure 2. Location of Haiti in the Caribbean (World Atlas, n.d.).

Prostate Cancer in Haiti

Haiti is a nation located in the Western Caribbean occupying the smallest part of the island of Hispaniola whereas, the Dominican Republic occupies the rest. The country has an estimated population of 10,000,000 with a mortality rate of 8.1 per 100,000 persons of the population. Life expectancy is at 62.51 years for the total population with health expenditure at 6.9% of GDP as reported in 2010 (Central Intelligence Agency: The

World FactBook, n.d.). Compounding Haiti’s long known status as the poorest country in the Western hemisphere is the 2010 massive earthquake measuring 7.0 on the Richter scale that left the country in its worst shape. It was reported in 1998 that Haiti’s physician density was at 0.25 per 1,000 persons and hospital beds at 1.3 per 1,000 persons in 2007. The Haitian health care system became nearly non-existent after the earthquake, leaving first response care to Doctors without Borders and other non- governmental organizations such as the Cuban Brigade (Ekine, 2013).

The Haitian government has formed a health partnership with the United States

Agency for International Development (US AID) aiming to advance Haiti’s ownership and oversight of an adaptable and self-correcting public health system and reduce its dependence on donor support over time (US AID, 2014). Moreover, the challenges that

Haiti faces remain enormous. From economic adversity to natural disasters including the cholera epidemic, the increasing incidence of prostate cancer in Haitian men of which

80% of diagnosed cases succumbed is certainly a noteworthy added burden to Haiti. Any advancement of research that can play a role in aiding the Haitian government in addressing the mortality rate in Haitian men is significant.

The literature supports a high correlation between early prostate cancer screenings with low mortality rate from the disease. It was reported in 2007 that Haiti had 767 cases of prostate cancer per 100,000 individuals, with a mortality rate of 403 (International

Agency for Research on Cancer, 2005). Prostate cancer mortality rate remains high in

Haiti. In fact, the incidence and mortality rates have increased. The most recent report of the global burden of cancer reported 1,228 diagnosed cases and 979 deaths from prostate cancer in Haiti (GLOBOCAN, 2012). Considering the data, the mortality rate is about

80% of the incidence rate. Therefore, the survival rate is only about 20% as compared to

American men (5 years’ survival rate at 100%, 10 years at 99%, and 15 years at 94%)

(American Cancer Society, n.d.). Currently, Haiti is ranked 10th in the world in prostate cancer mortality rate, and prostate cancer holds the 12th position in the top-20 leading causes of death in Haiti (World Life Expectancy, n.d.).

Figure 3. Haiti's states and capital (University of Texas, 1999).

There is no systematic screening for cervical, breast, or prostate cancer in Haiti

(Pan American Health Organization, 2007). Generally, health guidelines and recommendations from PAHO are adopted and followed. The Minister of Health in Haiti recognizes that the country is in great need and confers that a partnership with PAHO is essential for future advancement (Guillaume, 2013). There is a new initiative taken by the Minister of Health of Haiti (La Ministere de la Santé Publique et de la Population

[MSPP]) to fight against cancer. This initiative is being led with the assistance of cancer experts from the University of Florida and the University of Miami. It is sponsored by

Living Hope Haiti, a non-governmental organization (MSPP, 2015).

PAHO’s general recommendations for prostate cancer screening align consistently with the CDC, the NIH, the ACS, and the WHO. Given the lack of resources of Haiti, the DRE is practically more achievable because it is basically costless or cost- effective. However, the Haitian’s culture may pose a barrier for men with regard to the

DRE. As previously defined, the DRE is the palpation of the prostate gland through digital manipulation via the rectum (Baker, 2009). It is performed by a healthcare practitioner inserting a gloved, lubricated finger into the rectum to examine the posterior surface of the prostate gland; estimate the size, shape, and consistency of the prostate; and feel for lumps and nodules or other abnormalities (CDC, 2013). Homosexuality is tabooed in the Haitian culture (Colin & Paperwalla, 2013); hence, such a procedure may be perceived as unacceptable. Limited research has attempted to investigate the perceived factors contributing to the low participation rate of Haitian men in prostate cancer screening. Moreover, very little is known regarding the possible causes for the high mortality rate in Haitian men. These significantly high levels of mortality require

16 investigation to determine what strategies could be developed to achieve a decrease in the mortality rate of Haitian men.

Problem Statement

Prostate cancer is one of the top five cancers posing a threat to the lives of men worldwide (GLOBOCAN, 2012). Nonetheless, early detection of prostate cancer through the use of screening tools including prostate specific antigen (PSA) test and digital rectal exam (DRE) are key factors to increasing survival rates (American Cancer

Society [ACS], 2007). Haitian men suffer high and increasing morbidity and mortality rates of prostate cancer; yet, their participation in prostate cancer screening remains low

(Kleier, 2010). The most recent report of the global burden of cancer reported 1,228 diagnosed cases of prostate cancer and 979 deaths per 100,000 persons of the population of Haiti (GLOBOCAN, 2012). Few studies have explored the predictive relationship of

Haitian men’s perception of their risk of developing prostate cancer and their benefits of and barriers to prostate cancer screening to the intention of participating in prostate cancer screening. Therefore, a study that focuses on Haitian men’s intention regarding prostate cancer screening should provide nurses with the insight on how to better care for, address, and educate Haitian men with regard to prostate cancer.

Purpose Statement

The purpose of this study was to determine which of these selected constructs of the Health Belief Model (perceived susceptibility, perceived benefits, and perceived barriers) are predictors of the intent of Haitian men to participate in prostate cancer screening. The study also explored the relative contributions of these selected

17 demographic variables (age, level of education, marital status, religion, and family history) to Haitian men’s intention regarding prostate cancer screening.

Theoretical and Operational Definitions of Key Terms

The following terms are being defined in both theoretical and operational manners as they are discussed throughout the study.

Perceived Susceptibility

Theoretical definition. Perceived susceptibility refers to an individual’s belief of the likelihood of getting a disease or condition. Thus, the HBM predicts that individuals who perceive that they are susceptible to a disease will engage in behaviors that would help reduce the risk of developing the disease (Champion & Skinner, 2008).

Operational definition. Perceived susceptibility was measured by items one through five of the Champion Health Belief Model Scale (CHBMS). The responses are rated on a 4-point Likert scale, ranging from strongly disagree to strongly agree . The response to the items pertaining to “perceived susceptibility” were added to attain a composite score reflecting the level of perceived susceptibility. A high score represents a high level of perceived susceptibility, whereas a low score represents a low level of perceived susceptibility.

Perceived Benefits

Theoretical definition. Perceived benefits refer to an individual's assessment of the value or efficacy of engaging in a health-promoting behavior to decrease the risk of a disease. The HBM proposes that the more benefits that individuals perceive that a particular action will have regarding a perceived threat, then the more likely they will

18 engage in that behavior regardless of objective facts concerning the effectiveness of the action (Champion & Skinner, 2008, University of Twente, n.d).

Operational definition. Perceived benefits were measured by the participant’s response to item six through 11 from the CHBMS. The responses are rated on a 4-point

Likert scale, ranging from strongly disagree to strongly agree . The responses to the items concerning “perceived benefits” were summed up to reach a composite score indicative of the level of perceived benefits. A high score signifies a high level of perceived benefits, whereas a low score signifies a low level of perceived benefits.

Perceived Barriers

Theoretical definition. Perceived barriers refer to potential complications involved with a particular health action. They are factors that act as impediments to undertaking recommended behaviors. The HBM suggests that the perceived benefits must outweigh the perceived barriers in order for behavior change or action to occur

(Champion & Skinner, 2008, University of Twente, n.d).

Operational definition. Perceived barriers were measured by the participant’s response to item 12-15 of the CHBMS. The responses were rated on a 4-point Likert scale, ranging from strongly disagree to strongly agree . The response to the items pertaining to “perceived barriers” were added to attain a composite score reflecting the level of perceived barrier. A high score denotes a high level of perceived barriers, whereas a low score denotes a low level of perceived barriers.

Intention

Theoretical definition. Behavioral intention is defined as a person's perceived likelihood or subjective probability that he or she will engage in a given behavior (Ajzen,

1991).

Operational definition. Intention was measured by the participant’s response to items 10 through 13 in the researcher’s developed demographic survey. The responses are rated on a 4-point Likert scale ranging from no to yes to determine the strength of intention. The response to the items addressing “behavioral intention” were summed to attain a composite score reflecting the strength of the intention. A high score represents a strong intention, whereas a low score represents a weaker intention.

Research Questions and Hypotheses

This study examined a total of seven questions with their corresponding hypotheses. The first question focused on the predictive relationship between some selected Health Belief Model constructs and the intention of Haitian men regarding prostate cancer screening. The second question sought to reveal the most significant predictor of the select constructs. The third question sought to determine if there is a relationship between Haitian men of different ages and their intent to screen for prostate cancer. The other four questions focused on the relative contribution of four select demographic variables (levels of education, marital status, religion, and family history) by examining the differences of Haitian men’s intent to screen for prostate cancer as influenced by these variables.

Research Question and Hypothesis One

RQ1: What is the relationship between select constructs of the health belief model

(perceived susceptibility, perceived benefits, and perceived barriers) and the intention of

Haitian men in Haiti to screen for prostate cancer?

RH1: There will be a statistically significant positive predictive relationship between select constructs of the health belief model (perceived susceptibility, perceived benefits, and perceived barriers) and Haitian men’s intent to screen for prostate cancer.

Research Question and Hypothesis Two

RQ2: Which of these select health belief model constructs (perceived susceptibility, perceived benefits, and perceived barriers) is the most significant positive predictor to the intention of Haitian men in Haiti to screen for prostate cancer?

RH2: Perceived susceptibility will be statistically the most significant positive predictor to intention of Haitian men in Haiti to screen for prostate cancer.

Research Question and Hypothesis Three

RQ3: What is the relationship between Haitian men of different ages and their intent to screen for prostate cancer?

RH3: There will be a statistically significant positive relationship between

Haitian men of different ages and their intent to screen for prostate cancer.

Research Question and Hypothesis Four

RQ4: What is the difference of intent to screen for prostate cancer among Haitian men of different levels of education?

RH4: There will be a statistically significant difference of intent to screen for prostate cancer among Haitian men of different level of education.

Research Question and Hypothesis Five

RQ5: What is the difference of intent to screen for prostate cancer among Haitian men of different marital status?

RH5: There will be a statistically significant difference of intent to screen for prostate cancer among Haitian men of different marital status.

Research Question and Hypothesis Six

RQ6: What is the difference of intent to screen for prostate cancer among Haitian men with different religions?

RH6: There will be a statistically significant difference of intent to screen for prostate cancer among Haitian men with different religions.

Research Question and Hypothesis Seven

RQ7: What is the difference of intent to screen for prostate cancer between

Haitian men with or without family history of prostate cancer?

RH7: There will be a statistically significant difference of intent to screen for prostate cancer between Haitian men with or without family history

Theoretical Framework

The low participation rate of Haitian men in prostate cancer screening may be influenced or caused by many factors. The intriguing question is: What is a plausible explanation for their low participation rate? What can be established with certainty regarding this issue? What is the truth? These questions fit well in the realm of positivism (Welford, Murphy, & Casey, 2012, p. 31). Hence, the paradigm that frames this problem area of interest is positivism. Consequently, positivism will be briefly explored and discussed in the next section.

Positivism

Positivism is the philosophy of science that holds that knowledge originated from logical and mathematical developments and reports of sensory experience—that is, the exclusive source of all authoritative knowledge (Macionis, 2012). The term “positivism” was coined by the philosopher and sociologist Auguste Comte in the early 19th century

(Rogers, 2005). Some other philosophers who contributed to positivism in the 19th century were Mills, Newton, and Locke (Polit & Beck, 2012). According to Comte, positivism accounted for how people explained the world around them. Comte presented in his work that societies pass through three different essential stages: theological stage – relating explanation to the supernatural forces, metaphysical stage – relating explanation to abstracts such as energies and ideas, and positive stage – relating explanation to scientific principles (Rogers, 2005). Positivism holds that society, like the physical world, operates according to general laws. Contemplative and instinctive knowledge are rejected (Macionis, 2012).

The major assumptions of positivism lie within their strong belief of facts, empirical data, and experiments as the basis of real science (Glanz and Rimer, 2005;

Rogers, 2005). These assumptions can be discussed through these four views: ontological, epistemological, axiological, and methodological. From an ontological view, it is believed that reality exists, and there is a real world energized by causes and effects.

From an epistemological view, the researcher is totally independent from those being researched. Therefore, the results or findings should be free from the researcher’s bias.

From the axiological view, personal values and biases are to be controlled and contained.

Objectivity is the goal. Finally, from the methodological, knowledge is acquired through

23 deductive processes, fixed and pre-specified designs, focused on objective and quantifiable, based on large samples, and seeks generalization (Polit & Beck, 2012, p.

13).

The philosophy of logical positivism has derived from positivism. The word

“logical” was added to reflect the intention of incorporating logic into positivism

(Rogers, 2005). The main group responsible for this movement was the “Vienna Circle.”

The work of Gottlob Frege, Bertrand Russell, and Alfred North Whitehead provided the infrastructure for the Vienna Circle discussion on logic. The work of the Vienna Circle generated a great influence on the structure of the path for knowledge advancement

(Crotty, 2012).

In summary, the major goal of positivism is objectivism. This philosophy holds that there is an orderly reality that can be objectively studied; the research method is usually associated with quantitative research (Polit & Beck, 2012). In Comte’s perspective, prediction comes from science and actions come from prediction. Therefore, positivism is a philosophy of human intellectual development that culminated in science

(Macionis, 2012). According to logical positivism, the primary purpose of science is to predict, explain, and control occurrences (Rogers, 2005). Hence, this study utilized the

Health Belief Model as theoretical framework which is well aligned with this paradigm.

In addition, the Purnell Model for Cultural Competence was applied as a supportive framework but was not tested in this study.

The Health Belief Model

The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. The major focus is on the attitudes and beliefs of

24 individuals. The model grew from two major learning theories: stimulus response (S-R) theory and cognitive theory (C-T). In S-R theory, reasoning and thinking is not required; learning results from events (reinforcements) that reduce physiological drives that activate behavior. In cognitive theory, the thought process is essential; reinforcements operate by influencing expectations about the situation rather than by influencing behavior directly (Champion & Skinner, 2008). The Health Belief Model was developed in the 1950s by social psychologists Irwin M. Rosenstock, Godfrey M. Hochbaum, S.

Stephen Kegels, and Howard Leventhal at the U.S. Public Health Service to better understand the widespread failure of screening programs to prevent and detect disease.

The model was developed in response to the failure of a free tuberculosis (TB) health screening program. Since then, the HBM has been adapted to explore a variety of long- term and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS (Babbie, 2010; Champion & Skinner, 2008). The HBM is one of the most widely used conceptual frameworks in health behavior research, both to explain change and maintenance of health-related behavior and as a guiding framework for health behavior interventions.

The HBM has several constructs that explain or predict why people will take action to prevent, to control, or to screen for a disease. These constructs include perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy (Champion & Skinner, 2008; University of Twente, n.d).

Along with these constructs, the notion of perceived threat is also mentioned but not defined individually. It is rather a combination of two of these constructs.

Perceived Susceptibility

Perceived susceptibility refers to the likelihood of getting a disease or condition.

Thus, the HBM predicts that individuals who perceive that they are susceptible to a disease will engage in behaviors that would help reduce the risk of developing the disease

(Champion & Skinner, 2008; University of Twente, n.d). For example, if a man belongs to a family of which several male members were diagnosed with prostate cancer, he might feel more susceptible to prostate cancer thereby agreeing to screen for prostate cancer.

Perceived Severity

Perceived severity refers to the feeling of seriousness of contracting the disease or leaving it untreated. The HBM suggests that the more serious that individuals perceive a health problem is, the more likely they will engage in behaviors to prevent it from occurring or reduce its severity (Champion & Skinner, 2008). Similarly, if a man is aware of the horrific consequence of prostate cancer if left untreated, he might be prompted to be screened for early detection. In contrast, the lack of knowledge regarding the severity of prostate cancer might cause a man not to seek to be screened for prostate cancer.

Perceived Benefits

Perceived benefits refer to an individual's assessment of the value or efficacy of engaging in a health-promoting behavior to decrease the risk of a disease. The HBM proposes that the more benefits that individuals perceive that a particular action will have regarding a perceived threat, then the more likely they will engage in that behavior

26 regardless of objective facts regarding the effectiveness of the action (Champion &

Skinner, 2008; University of Twente, n.d). If a man believes that getting screened for prostate cancer can help increase early detection and consequently reduce morbidity, he will more likely have the intent to screen for prostate cancer. However, if the man believes that screening for prostate cancer is not so beneficial, he is less likely to utilize the screening tools.

Perceived Barriers

Perceived barriers refer to potential complications involved with a particular health action. They are factors that act as impediments to undertaking recommended behaviors. The HBM suggests that the perceived benefits must outweigh the perceived barriers in order for behavior change to occur (Champion & Skinner, 2008). The man must believe that it is worthwhile for him to go through any hurdle in order to seek to be screened for prostate cancer. If the man believes otherwise, the intent to screen for prostate cancer will simply disappear.

Cues to Action

Cues to action refer to the internal or external cues that prompt the action. The

HBM theorizes that a cue, or trigger, is necessary for prompting engagement in health- promoting behaviors. Internal cues can be physiological such as pain, whereas external cues can be an event or a billboard sign (Champion & Skinner, 2008; University of

Twente, n.d). For example, if a man’s close relative recently was diagnosed with prostate cancer, this man is more likely to have the intent to screen soon for prostate cancer.

Likewise, if there is no close occurrence, he is less likely to have the intent to screen for prostate cancer.

Self-Efficacy

Self-efficacy refers to an individual’s perception of his or her competence to successfully perform a behavior. The HBM recognizes that confidence in the individual’s ability to effect change in outcomes is crucial to health behavior change

(Champion & Skinner, 2008; University of Twente, n.d). Equally, if a man feels confident that he can go through the process of getting screened for prostate cancer, then he is more likely to go through with it.

The Notion of Perceived Threat

To address the phenomenon of interest of this study, three of the original four constructs (perceived susceptibility, perceived benefits, and perceived barriers) were selected. Perceived severity was omitted because it has been found to have very little variance with perceived susceptibility (Champion, 1999). It is also important to point out that the combination of perceived susceptibility and perceived severity is also referred to as perceived threat (Becker, 1974; Becker & Janz, 1985). Perceived threat is considered the most predictive construct with regard to health related behavior (Champion &

Skinner, 2008). Due to the slight variance found with perceived severity, perceived threat can be measured by perceived susceptibility alone without perceived severity

(Champion, 1999; Champion et. al., 2004). For this study, perceived threat was evaluated by utilizing the construct of perceived susceptibility alone. The HBM maintains that the greater the perceived threat, the greater the likelihood of engaging in behaviors to decrease the threat. In addition, the perceived benefits speak directly to the merit of the new behavior. People incline to implement healthier behaviors when they

28 believe the new behavior will decrease their likelihoods of developing a disease.

However, the perceived benefits may be influenced by the perceived barriers. The barriers may be so overwhelming, thereby overshadowing the benefits of the healthier behavior. Hence, the benefits must always outweigh the barriers.

The Health Belief Model

Figure 4. The standard schema of the health belief model.

These three constructs, perceived susceptibility, perceived benefits, and perceived barriers, were selected because they were better aligned with the purpose of the study, and they correlated well with the assumptions of the model. Some of the HBM constructs have been found to have cultural differences. For example, although self- efficacy was found to be a strong predictor regarding increased condom use, it was found to be significantly lower among Asian-American than in White, Hispanic, and African-

Americans (Hounton, Carabin, & Henderson, 2005; Lin, Simoni, & Zemon, 2005). Such differences may present among genders or varies among ethnicity. However, for perceived susceptibility, perceived benefits, and perceived barriers, the literature supports their consistency in construct validity when translated into other cultures—Arabic,

Turkish, Korean, and Chinese (Champion & Skinner, 2008). For this study, these three constructs were utilized to determine the intent of Haitian men in Haiti regarding prostate cancer screening.

Modifying Factors Individual Perceptions

Age, Education, Marital Status, Perceived Benefits

Family History, Religion minus Perceived Barriers

Prostate cancer screening can save my life. Nothing should stop me from Individual Perception getting screened.

Perceived Susceptibility Likelihood of Action It is more likely for me

to be prostate cancer. Likelihood of Behavior

I will get screened for prostate cancer.

Perceived Threat

I may die from prostate cancer if left untreated.

______

Figure 5. Louis' (2016) adaptation of the health belief model for application to prostate cancer screening.

Relationship of HBM to the Study

The study aims to identify any predictors of Haitian men’s intention with regard to prostate cancer screening using these HBM constructs: perceived susceptibility, perceived benefits, and perceived barriers. Perceived susceptibility comes first. The man identifies if he is at risk or not of contracting prostate cancer; then, he acquires

31 information and understanding on how serious is prostate cancer. These perceptions combined will determine the level of threat he is facing. As Champion (1999) noted, there is very little variance with perceived severity; hence, perceived threat becomes eminent with perceived susceptibility alone. Therefore, in this study, the terms perceived susceptibility and perceived threat were used interchangeably. As depicted in the schema, perceived threat may be influenced by several or a combination of modifying factors. A person’s perception of a disease may differ based on that person’s age, gender, ethnicity, socioeconomic, education, or knowledge. These modifying factors may influence the man’s perceived threat of prostate cancer, which in turn may influence the action he will take with regard to prostate cancer screening. In addition, cues to action— which is considered as a strategic reminder—may potentiate the level of threat and encourage the man to take action. However, if the perceived threat is intense enough, a cue to action may not be necessary. In summary, the man’s perceived threat of prostate cancer may determine his intention of getting screened for prostate cancer.

In addition, the schema noted that the HBM constructs are interconnected.

Nonetheless, a man’s perceived threat alone can predict his likelihood of taking action. A similar characteristic is also noted for perceived benefits and perceived barriers. For example, if a man’s perceived benefits of prostate cancer screening are great and his perceived barriers to actually get screened are minimal, he is most likely to be screened for prostate cancer even if he does not feel threatened by prostate cancer. Hence, perceived barriers must not in any way supersede perceived benefits. Similarly, to perceived threat, perceived benefits and perceived barriers can also be influenced by

32 modifying factors. Nevertheless, all of these three select constructs have a direct impact on the likelihood of behavior.

Although the health belief model has been used in diverse populations, it lacks the presence of cultural elements to explain or predict health behaviors. Haiti is a country that is unique in many aspects. Despite its vast cultural similarities with its neighboring countries in the Caribbean, the Haitian culture in itself is more complex than it seems

(Girard, 2010). The culture is deeply rooted within the history of the country. In the colonial years, Haiti was known as the pearl of the Caribbean, and over time, it has borne many names including the magic island, land of danger, land of mystery, and land of the supernatural (Dash, 2001). Although Haiti defines itself as a black nation, the complexity of its social stratification lies within many shades of differences (Colin & Paperwalla,

2013). Hence, it is imperative to apply an additional lens that is a culturally focused framework to conduct this study. To bridge this gap, the Purnell model for cultural competence was utilized as the additional lens through which this study was conducted.

The Purnell Model for Cultural Competence

Larry Purnell, a nursing professor, developed the Purnell model for cultural competence in 1995. The model sprang forth from Purnell’s observations while taking nursing students to a community hospital for clinical instruction. (Culture Competence

Project, 2014). The model provides a framework to help create a culture competent atmosphere within the health care field. It provides a path for better exchanges between the health care provider and the patient (Purnell & Paulanka, 2003). Furthermore, the model can serve as a tool for health care providers to better understand their own cultural beliefs, attitudes, values, practices, and behaviors. The schema of the Purnell model for

33 cultural competence is a circle (Figure 6). The outlying rim of the circle represents the global society, the second rim of the circle represents the community, the third rim of the circle represents the family, and the innermost rim represents the individual (Culture

Competence Project, 2014).

Figure 6. The Purnell (2013) model for cultural competence.

The circle is divided into 12 pie-shaped wedges portraying cultural constructs and their associated concept. The dark center of the circle denotes unknown phenomena.

These 12 cultural constructs are communication, family roles and organization, workforce issues, biocultural ecology, high-risk behaviors, nutrition, pregnancy, death rituals, spirituality, health care practices, health care practitioners, and overview/heritage

(Purnell, 2013). These 12 cultural constructs yield the organizing framework for this model. It must also be noted that no single construct stands alone; they are all interrelated. This model has been applied as a supplemental lens in many studies when dealing with culturally diverse populations (Dunn, 2002; Mebrouk, 2008). Fortunately for this research, Colin and Paperwalla (2013) have addressed all the 12 cultural constructs of the model with regard to the people of Haitian heritage. Their work served as the balancing platform, which helped shape the findings of this research as culturally competent to Haitian men.

Assumptions

Theoretical Assumptions

The assumptions of the study are parallel to the ones of the HBM. The HBM is based on the assumptions that a person will take a health-related action (i.e., participate in prostate cancer screening) if that person: (a) feels that a negative health condition (i.e., prostate cancer) can be avoided; (b) has a positive expectation that by taking a recommended action (i.e., getting screened will be effective at detecting prostate cancer); and (c) believes that recommended health action can be achieved successfully (i.e., able to schedule for prostate cancer screening comfortably and with confidence) (University of Twente, n.d). In summary, the assumption was Haitian men’s intention to screen for

35 prostate cancer will be determined by their perceived susceptibility (perceived threat), perceived benefits, and perceived barriers with respect to prostate cancer.

One of the assumptions of this study is that the health belief model is suitable to guide this particular study. Because the HBM has been utilized by many studies as a framework, it is assumed that it is supported empirically. Furthermore, the Champion

Health Belief Model Scale (CHBMS) is valid and reliable as referenced in many studies.

Therefore, the CHBMS will be effective in measuring the variables of the study.

Additionally, it is the assumption the Purnell model for cultural competence is empirically supported and suitable to address the cultural aspect of the research. The model is based on the general assumption that no one culture is better than another; they are simply different from each other. The model embraces that fundamental similarities are shared by all cultures. Hence, prejudices and biases can be lessened with cultural understanding (Purnell, 2013). In addition, the model assumes that every patient’s contact is a cultural encounter. Therefore, since cultural competence is a process, every patient’s encounter counts toward the process of competency.

Researcher Assumptions

With regard to the sample population, it is assumed that participants will complete the self-reported questionnaires honestly. The married men will more likely be willing to be screened for prostate cancer. The assumption is that they will be more likely influenced by their wives to follow up with health professionals’ recommendations. The younger Haitian man will be more inclined to be screened for prostate cancer than the older Haitian man. Moreover, the higher the level of education of the Haitian man, the more positive his intention for prostate cancer screening. Similarly, for the family history

36 of prostate cancer, if the Haitian man has a family history of prostate cancer, the more positive his intention will be to be screened for prostate cancer.

Significance of the Study

Essentially, this particular study may help bridge a wide gap that currently exists in the literature regarding prostate cancer screening. Part of the gap is the perception of men belonging to a more reserved culture or less familiar with the Western healthcare system of prostate cancer screening. Can perceived susceptibility overcome perceived barriers, especially cultural barriers, to allow for positive health behavior? Cultural competence is based on the assumption that culture plays a powerful role on how an individual interprets and responds to health care (Purnell, 2013). This study may bring forth understanding about Haitian men’s intention regarding prostate cancer screening; it may also identify predictors of their intention. Furthermore, this study may serve as a path towards future research regarding Haitian men’s health and other similar populations.

Significance of the Study to Nursing

Haitian men face a high risk of prostate cancer incidence with a high mortality rate. The incidence and mortality rate continue to increase. Very little is known regarding the reasons for the high mortality rate of prostate cancer in Haiti. Moreover, there is a limited amount of research addressing prostate cancer concerning the Haitian men population. This study aims to explain the phenomenon of why Haitian men’s participation rate in prostate cancer screening is so low and to predict Haitian men’s intention regarding prostate cancer screening using the health belief model (HBM) constructs. The findings of this study may have implications for nursing professionals in

37 multiple areas such as nursing education, nursing practice, nursing research, and health/public policy. Thus, it could play a positive role in decreasing the mortality rate in

Haitian men by bringing forth understanding on how to help increase their participation.

Implications for Nursing Education

The limited studies that address prostate cancer among Haitian men significantly highlight the correlation between the lack of knowledge and the low participation rate in prostate cancer screening. Thus, Haitian men’s knowledge regarding prostate cancer and prostate cancer screening must be addressed. Nurses are the beacons of preventive health education. More information from these findings could help nurses understand the importance of being competent in Haitian men’s perception of prostate cancer and their intention to participate in prostate cancer screening. Furthermore, the findings should serve as a guide to help reshape or improve the nursing curriculum of prospective nurses, especially nursing students in Haiti. Their understanding of how Haitian men perceive their susceptibility to prostate cancer, their perception of the benefits of prostate cancer screening, and the actual barriers that exist in preventing them from getting screened will lead toward progressive prevention. They may be able to address the perceptions and the myth surrounding prostate cancer screening.

Implications for Nursing Practice

As clinicians, nurses are at the forefront of patient care. Thus, nurse practitioners will come across many Haitian male patients who will need to be examined, educated, and perhaps treated for prostate cancer. Advance knowledge specifically focused on

Haitian men is essential for these clinicians in order to ten to them more efficiently. The findings of this study may help nurse practitioners’ approaches to be more in line with the

38 health care ideologies and values of this population. Hence, nurse practitioners may be better equipped to understand Haitian men’s perceived barriers to participate in prostate screening. Thereby, they may be able to engage, educate, and encourage Haitian men to take appropriate action with regard to prostate cancer screening. Once Haitian men are being educated accordingly, an increase in prostate cancer screening participation may be noted.

Implications for Nursing Research

A great deal of research on prostate cancer exists in the literature. Much of this research addresses prostate cancer concerning African-American men, and the conclusion is usually the well-established fact of their high risk status. However, there is a paucity of published research focused on Haitian men about this issue. It is a common mistake to equate race with ethnicity. The U.S. Census Bureau categorizes Haitian men as African-

American in the United States. A clear gap in the literature exists regarding prostate cancer in Haitian men. This gap needs to be addressed to advance nurses’ knowledge with regard to Haitian men and prostate cancer. Furthermore, none of the published studies exploring this issue among Haitian men examined the relationship of the HBM constructs and Haitian men’s intention to participate in prostate cancer screening. In addition, none of the studies considered to investigate the meaning attached to Haitian men’s perceived barriers and the critical factors that may have influenced Haitian men’s behavior of low participation in prostate cancer screening. Understanding the meaning of the perceived barriers and discovering the influential factors of their attitude and perception, might impact their participation in prostate cancer screening. It may indicate the need for more research, including a qualitative perspective.

Implications for Health/Public Policy

Any development in health science and the delivery of care would be beneficial to a governmental community, particularly because health care policies have always been cost-driven. The common goal of any health care policy is to reduce diseases and the high cost of treatment delivery, whereas public policy focuses on the safety and the well-being of the public as a whole. The findings of this study may help in guiding the Haitian government and any other country with a prominent Haitian population in developing their public and health care policies accordingly, especially with respect to fund allocation. In health care, primary prevention has proven for a long time to be more cost- effective than secondary and tertiary prevention. The results of this study may provide directions as to how to address primary prevention with Haitian population concerning prostate cancer.

Scope and Limitations of the Study

The scope of this study focused within the parameters of the HBM select constructs (perceived susceptibility, perceived benefits, and perceived barriers). The study investigated whether these constructs are predictive indicators of the intent of

Haitian men regarding participation in prostate cancer screening. This study also examined if there is a relationship between select demographic variables (age, level of education, marital status, religion, and family history) and the intent of Haitian men regarding participation in prostate cancer screening. Moreover, the study focused specifically on a purposeful and convenient sample of Haitian men of a specific age range living in Haiti. Their participation was voluntary. All participants received the same demographic questionnaire developed by the researcher. They were also surveyed via a

40 modified Champion Health Belief Model Scale (CHBMS). For the consideration of cultural competence in the studied population, the Purnell model for cultural competence was employed, and the study was conducted within the parameter of its 12 constructs.

No other related association beyond the scope of the study was heeded in the findings of this study.

As Creswell (2003) indicated, the intricacy of human nature and the inability to control for all probable variables are inherent limitations in this and all social science studies. Evidently in addition to the scope of the study, the limitations include the factors that pose a threat to the external and internal validity of this study. In addition, the sample for this study was recruited through convenience purposeful sampling, which defied the opportunity for randomization. The sample was drawn from Haitian men living in Haiti who may have had limited exposure to similar activity. The findings were partial to the use of self-reported surveys, the use of translated tools, and the inconvenience of time allotted to complete the survey, inquiring about information that may not be fully understood. The findings of this study depended on responses expected to be honest from volunteers who agree to take the modified CHBMS survey. Another limitation of the study was the possibility of having surveys completed twice by the same participant. Given that collection of surveys occurred over a period of 2 weeks, the likelihood of such occurrences was probable. Moreover, the presence of the researcher may have induced more socially desirable answers from the participants, which could affect the results of the study. Finally, the study was conducted by a novice researcher.

The limited experience of such a researcher may have influenced the outcome of the study.

Threats to External and Internal Validity

Validity is defined as a quality criterion referring to the degree to which inferences made in a study are accurate and well-founded (Polit & Beck, 2012).

Essentially, validity represents the verity of the findings as indicated by the authenticity of the design (Wood & Ross-Kerr, 2011). It is the certainty of the relationship between the independent variable and the dependent variable. Consequently, it is important to account for and attempt to eliminate or reduce threats to validity in order to substantiate the relevance of the effect of the independent variable on the dependent variable. Hence, any threat to the validity of a study poses the risk of nullifying its purpose.

Threats to External Validity

External validity refers to how well a study from one setting can be applied to another. It is the ability to generalize across categories or classes of individuals and across settings within the same target population (Rovai, Baker, & Ponton, 2013). The sample was recruited from various places where there was a high concentration of

Haitian men. All the participants volunteered to take part in this study. In other words, the sample was basically self-selected. This bias of self-selection—due to the absence of randomization—may have lessened the probability for generalization, which in turn may have posed a threat to external validity. In addition, the sample being drawn from limited geographic areas in Haiti may not be fully representative. Despite the fact that the similarity of being Haitian men living in Haiti takes precedence, regional culture may be a factor causing inconsistency.

Threats to Internal Validity

Internal validity is the extent to which one can accurately state that an intervention produced the observed effect (Rovai et al., 2013). In other words, the study accomplished its goal. The results of this study consist of information collected via a self-report process. This method is the most common approach used to collect data, measuring opinion, interest, values and feelings. It is possible that participants may answer according to what is expected of them or what is more socially acceptable.

However, only the participants are deemed qualified to express their own perception regarding their susceptibility to prostate cancer, the benefits of being screened for prostate cancer, the barriers of getting screened for prostate cancer, and their intention to be screened for prostate cancer. To enhance the internal validity and lessen the threat, great emphasis was placed on the anonymity of the answers to the survey. Therefore, the behavioral conformity or normality was not at all necessary. This notion was consistently expressed and explored with the participants.

Chapter Summary

This chapter discussed the general purpose of the study. It included the background of the high prevalence of prostate cancer among Haitian men and their low participation rate in prostate cancer screening. The problem statement was presented along with the specific purpose of the study. The key terms discussed in this study were defined both theoretically and operationally. The study posed a total of seven questions along with their corresponding hypotheses to address the problem. The theoretical frameworks that guided the study were both discussed separately. The main theoretical framework is the health belief model. It was discussed thoroughly along with its

43 relationship to the study. In addition, an overview of the complementary framework, the

Purnell model for cultural competence, was presented. Assumptions of the study were explored, including the theoretical assumptions and researcher assumptions. The significance of the study and to nursing was conferred. The scope and limitations of the study were explored, including the threats to external and internal validity. In summary, the study focused on the predictive relationship between some select HBM constructs and the intention of Haitian men in participating in prostate cancer screening.

CHAPTER TWO

LITERATURE REVIEW

The purpose of this study was to determine which of these selected constructs of the health belief Model (perceived susceptibility, perceived benefits, and perceived barriers) are predictors of the intent of Haitian men to participate in prostate cancer screening. The study also explored the relative contributions of these selected demographic variables (age, level of education, marital status, religion, and family history) to Haitian men’s intention regarding prostate cancer screening. In order to address the purpose of this study, a substantial review of the literature regarding the phenomenon of interest was conducted. The literature review is the amalgamation of the literature on a specific topic. Polit and Beck (2012) defined literature review as the critical summary of research on a topic of interest, often prepared to put a research problem in context. It is generally used to justify the significance of the study, place the study in historical perspective (how past studies have contributed to present studies), help refine the research questions, and identify an appropriate theory of methodology to guide the study (Cottrell & McKenzie, 2011).

A relevant literature search was conducted across disciplines to explore the phenomenon of screening for prostate cancers. Using First Search, Lilinet Online, and

ProQuest Direct search engines, the following computerized databases were used for this search: ABI Inform (index of Business and Management), ArticleFirst., the Cumulative

Index to Nursing and Allied Health Literature (CINAHL), Dissertation Abstracts,

Educational Resource Information Center (ERIC), Health Reference Center - Academic,

Medicine, Modern Language Association (MLA), and Periodical Abstracts (PerAbs:

Covering business, economics, literature, religion, psychology, and women studies). The key words used in the search were prostate cancer, prostate cancer screening, screening, Haitian men, and African-American men. Citations were limited by language to English and by subject to exploration of the concepts. A restriction was imposed to find literature published from 2004 to present. For this particular search, the timeframe was extended due to the scarcity of research found addressing prostate cancer with regards to Haitian men. The literature references that were found about this phenomenon of interest were delineated through a random selection method, reviewed for the perspectives and rationale for the significance of prostate cancers screening.

The literature review was divided into context with respect to the perspectives taken by the studies addressing prostate cancer screening. For this study, the review will evaluate studies as they fit under the following headings: Studies Using the Health Belief

Model as a Framework, Factors Influencing Health Care Seeking Behaviors, Factors

Influencing Prostate Cancer Screening, and Prostate Cancer Research Focusing on

Caribbean-born Black Men . Synthesis of the literature revealed what is known and not known about prostate cancer screening. A general recommendation from all the stakeholders is a call for more study to be generated to bring forth further knowledge on this matter.

Studies Using the Health Belief Model as a Framework

Coe, Gatewood, Moczygemba, Goode, and Beckner (2012) conducted a cross- sectional descriptive study to assess participants’ perceptions and attitudes about the severity, susceptibility, and risk of the novel H1N1 influenza virus and the novel H1N1 influenza vaccine. Other objectives of the researchers were to evaluate participants’

46 perceived benefits of and barriers to novel H1N1 influenza vaccination, identify participants’ cues to action, and determine the relationship between demographic and attitudinal variables and participants’ intention to receive novel H1N1 influenza vaccination. The health belief model (HBM) was used as the theoretical framework guiding this study. In general, the HBM has been used to explore patient motivations for adapting a health-related behavior and in assessing health-behavior interventions. The

HBM includes six key constructs that influence health behaviors: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy. All six constructs were utilized in this study. Since its development, the health belief model has been used in many populations to explore many different health-related topics. It has been found to be a reliable and valid tool to use as a framework while conducting research pertaining to health behaviors and health educational programs. In this section, the collation of these studies may serve as a well- represented variation of its use and reinforce the justification for its role in this study.

This study was conducted in the Central Virginia area at Virginia Commonwealth

University (VCU). The major criterion for participants was to be 18 years old or older.

A convenience sample was utilized to gather a total of 664 participants. Many college students were targeted due to their risk factors to H1N1 and the convenience of the recruiting process. Every participant was subjected to answer a 36-item questionnaire that was developed to assess the study objectives. The HBM constructs were addressed through 27 questions out of the 36; three questions were about participants’ intention to receive the vaccine and intention to vaccinate their child, if applicable, and the other six questions were about the demographic of the participants. Magenta for Office Forms

Designer, Data Blocks (Version 5.05, Gainesville, GA), Remark Office OMR Data

Center, Gravic, Inc. (Version 6.0.4, Malvern, PA) was the software used for data entry.

The data analysis was conducted through descriptive statistics (mean, standard deviation, frequency) for all variables. The HBM-based statements were grouped according to domains (perceived susceptibility to the virus, perceived severity of the virus, perceived clinical barriers to vaccination, perceived access barriers to vaccination, perceived specific vaccine benefits, and perceived general vaccine benefits statements).

For the domains with three or more items, their calculation was through Cronbach’s alpha. As for the domains with two items, a Pearson’s correlation was used to assess reliability. A scale mean was calculated for domains with an alpha coefficient or Pearson correlation > 0.5. There were three groups with the domain of cues to action: virus information sources, vaccine information sources, and health care professionals’ recommendations. The number of cues to action for virus and vaccine information sources was summed to create an overall number of exposures to information for the two groups. The health care professionals’ recommendations (physician, pharmacist, and nurse) were kept as separate variables. To assess the relationship between demographic variables, health belief model domains, and number of cues to action or recommendations with participants’ intention to receive the novel H1N1 vaccine, a logistic regression analysis was utilized. For the logistic regression analysis, the variable intention to receive the novel H1N1 vaccine was dichotomized into a likely to vaccinate group (very likely and likely) or an unlikely to vaccinate group (very unlikely and unlikely).

Regarding demographics and vaccination history as predictors of intention to receive the novel vaccination, the results indicated that the receipt of a seasonal influenza

48 vaccine last year was a significant predictor of intention to receive the novel H1N1 influenza vaccine. However, the participants who did not receive a seasonal influenza vaccine in the previous year were less likely to intend to receive a novel H1N1 influenza vaccine. As for the HBM constructs as predictors of intention to receive the novel H1N1 vaccine, the scale means for the perceived severity and perceived susceptibility of the novel H1N1 virus domains were 3.02 ( SD ± 0.76) and 3.72 ( SD ± 0.76), respectively.

The scale mean for the perceived clinical barriers domain was 2.38 ( SD ± 0.68). In summary, participants with lower perceived clinical barriers were more likely to intend to receive the novel H1N1 vaccine whereas there were no significant predictors of intention to vaccinate from the other HBM domains. Concerning cues to action as predictors of intention to receive the novel H1N1 vaccine, the study found that physicians’ recommendations to receive the novel H1N1 influenza vaccine were a significant predictor of intent to receive the vaccine. The participants who did not receive a recommendation from their physician were less likely to intend to receive the H1N1 vaccine.

D'Souza, Zyngier, Robinson, Schlotterlein, and Sullivan-Mort (2011) conducted a qualitative study using the health belief model to evaluate marketing promotion in a public vaccination program. The article did not indicate the specific type of qualitative design that was used for this study. Instead, the authors pointed out that the research was conceptual by nature using the health belief model as a framework. The objective of the research was to examine not just the development and delivery of a message targeting individual voluntary behavior change, but the intention of changes in social structures that will facilitate individuals reaching their potential. The underlined purpose of this

49 article is to explain the uptake process of the human papillomavirus (HPV) immunization using the health belief model (HBM).

The study was conducted in the Northern Metropolitan region of Melbourne,

Australia. The authors did not fully discuss the methodology of the research. They simply mentioned that their data were gathered from numerous focus groups categorized as follows: rural and metropolitan; English and non-English speaking background;

Australian-born and recent arrivals to Australia; and those of a high, middle, and low socioeconomic status. They spent a great amount of effort discussing their rationale for choosing focus groups rather than interviews. They believe the interaction among school-age children would be more effective in groups than in in-depth interviews and would provide adequate understanding of this sensitive topic. They also cited that focus groups are particularly useful for investigating people’s knowledge and their experiences.

They also proposed that focus group discussions can produce a far greater critical analysis on a topic than interviews. The number of the sample was not specified.

However, demographic information indicates that the participants ages ranged from 16 to

25, and those who were still in school were in 10th to 12th grade. They also reported that

80% of the participants were Australian-born.

The article did not mention any particular themes. However, the findings were discussed in relation to each construct of the health belief model utilized in the study.

With regard to perceived susceptibility, the researchers wanted to identify the level of awareness and belief of women of the HPV vaccine. They found that the majority of participants knew nothing or had only superficial knowledge about HPV prior to taking the vaccine. With regard to perceived severity, the researchers were to identify the

50 severity of the problem among women. They found that it was almost universally accepted amongst participants that to be vaccinated is for health prevention. The common comment was that they grew up with vaccination. Regarding perceived benefits, the researchers were to identify what perceived benefits would be received. They found that there was a difference between the focus groups in the relative importance of the vaccine being provided free of charge. Having the vaccine free of charge influenced many parents to have their children take the vaccine. Regarding perceived barriers, the researchers were to identify what personal barriers women have with this concept of immunization. Although there were some concerns regarding side effects of the vaccine, they were not considered as barriers. The women’s ambivalence about how well protected they would be after being vaccinated was not considered as a barrier either.

However, the primary barrier across the focus groups was the fear of needle. Along with the fear of needle, setting was also barrier. It was easier for people to follow through if the vaccination was taking place at a convenient location. Cues to action were achieved through word of mouth. For self-efficacy, all of the participants had been vaccinated before. Therefore, their previous experience helped to build up their confidence of going through this vaccination process.

Aghamolaei, Hasani, Tavafian, and Zare (2011) conducted a quasi-experimental study to assess the effect of an educational program on breast self-examination (BSE) among women living in Bandar Abbas, Iran. The study was guided by the health belief model as a framework. The sample ( N = 240) was drawn from eight health centers of

Bandar Abbas. The sample was randomly divided into intervention (n = 120) or control

(n = 120) groups. Champion’s Health Belief Model Scale (CHBMS) was utilized to

51 collect data regarding belief on breast self-examination. The CHBMS was translated into

Persian and adapted for Iranian culture. Cronbach alpha coefficients of CHBMS calculated for this study for susceptibility, seriousness, BSE benefits, BSE barriers and

BSE self-efficacy were 0.68, 0.77, 0.78, 0.77, and 0.87 respectively.

The researchers used independent t-tests to compare age and health belief model constructs between two groups before and after intervention. They also used chi-square to compare education, marital status, and breast health problems between two groups before intervention, and then it was used to compare breast self-examination behavior between two groups before and after intervention. The results found that there were no statistical differences between the two groups in terms of baseline data (all p > 0.05). In terms of the frequency of BSE behavior of control and intervention groups, there were statistically significant differences between two groups after intervention ( p < 0.001) whereas the two groups were the same at the beginning of the study ( p = 0.4). The findings of this study reinforced the need for health education programs based on HBM.

They recommend that health education programs such as breast self-examination should be based on HBM constructs. Consequently, such programs will be effective by augmenting perceived susceptibility, perceived seriousness, perceived barriers, and self- efficacy regarding BSE in women living in Bandar Abbas, Iran.

McNaughton-Collins and Barry (2011) conducted a qualitative study with a sample of 12 African-American men via the framework of the health belief model. The study aimed to examine the knowledge of, attitudes toward, and behaviors pertaining to prostate-cancer screening. The article did not mention any specific qualitative design.

From the sample, the age of seven of the men were from 38 to 49, and the other five were

52 ages 51 to 80. Data were collected through two focus groups with an open-ended questionnaire regarding prostate-cancer screening behaviors. No specific themes were reported in the article. The results showed that older men were more knowledgeable about prostate cancer and expressed less fear about the digital rectal exam than younger men. None of the participants were aware of the increased risk of prostate cancer among

African American men. They recommended that more education regarding prostate cancer screening is accessible to younger men in order to increase their awareness regarding this condition.

Oliver, Grindel, DeCoster, Ford, and Martin (2011) conducted a non- experimental exploratory study using a sample of 94 rural-dwelling male participants aged 40 and older. The objective of the study was to explore these three research questions: (a) What are the perceived benefits of screening for prostate cancer? (b) What are the perceived barriers to screening for prostate cancer? and (c) Is there an association with perceived benefits or perceived barriers and participants’ reported source of influence related to prostate cancer screening decisions? The instruments used included an adapted version of Champion’s (1999) revised Health Belief Model scale and a researcher-developed demographic and prostate cancer screening patterns form. To examine the association between cancer screening history and health beliefs, the researchers used chi squares with an alpha (α) of .05 as a determinant of statistical significance.

The demographic statistics found that the average age of the participants was 53.6

(SD = 59.3), with a range from 40 to 72 years. The majority of the participants were

African American (87.2%), and the rest were Caucasian. Over two-thirds were married

(75.5%); a little less than half (47.2%) reported to have a high school diploma or less, and the remainder had at least some postsecondary education. Regarding perceived benefits of screening, there was a high level of agreement with the statement “When I participate in prostate cancer screening, I feel good about myself’,” which was associated with self- report of having had a DRE (X² = 4.7, p = .03). Agreement with this statement was nearly signiﬁcantly associated with self-report of having had a PSA test ( X² = 3.1, p =

.08 ). Agreement with the statement “If I participate in prostate cancer screening yearly, it will decrease my chance of dying from prostate cancer” was associated with self-report of having had a DRE (X² = 6.7, p = .01). Regarding perceived barriers to screening, agreement with the statement “I am afraid to have a prostate cancer screening because I don’t understand what will be done” was correlated with not having had a DRE (X² = 6.1, p = .01) and not having a PSA (X² = 16.13, p < .0001). Agreement with the statement

“Prostate cancer screening will take too much time” was associated with not having had a

DRE (X² = 7.9 , p =.007) and not having a PSA (X² = 11.6, p = .001). Agreement with the statement “Participating in prostate cancer screening will be too painful” was associated with not having a PSA (X² = 4.7, p = .03).

The results indicated both benefits and barriers were significantly associated with prostate cancer screening and sources of influence. Health care providers and family were highly reported, at 81.8% and 59.5%, respectively, as sources of influence regarding prostate cancer screening decisions. In conclusion, significant barriers to prostate cancer screening among rural African-American men were identified. Prostate cancer health education may need to include family, whom study participants highly reported as a source of influence regarding their prostate cancer screening decisions.

Kleier (2010) conducted a correlational, cross-sectional study with a convenience sample of 143 Haitian-American men. The purpose of the study was to (a) examine if perceived susceptibility to prostate cancer was congruent with the objectively measured disease risk, (b) test the relationships of components of an integrated model consisting of perceived susceptibility and fear, and (c) examine these constructs for their predictive relationships to prostate cancer screening behaviors among Haitian-American men. An integrated model consisting of a construct from the health belief model and the extended parallel process model was utilized as the framework of the study. The author used bivariate correlational analysis using Pearson to assess her hypotheses. Regression analysis was also carried out to identify any predictive relationship between the variables.

The findings partially supported the integrated model in that perceived susceptibility was highly correlated (p < 0.05) to fear and screening behavior. Perception of risk was much lower than actual risk. Fear was not predictive of screening (p = 0.81). Kleier found that the health belief model was an appropriate framework to conduct this research on Haitian men with regard to prostate cancer screening. The results of the study indicated that

Haitian-American men do not recognize their increased risk for prostate cancer, so they are less likely to seek screening. Recommendations from the study include that Haitian-

American men must be educated on their true risk so they are adequately equipped to make an informed decision regarding screening.

Atulomah, Olanrewaju, Amosu, and Adedeji (2010) conducted a correlational cross-sectional survey utilizing a pre-tested 36-item questionnaire (Cronbach’s α of 0.62 ) to collect information about awareness, perception of susceptibility to prostate cancer, perceived seriousness of the disease, and perception of benefits of screening and

55 screening activities of men in a rural community of the Ikenne local government area of south-western Nigeria. A sample of 398 randomly selected males aged between 30 and

72 years responded to the questionnaire. Descriptive statistics such as frequency distributions and means were utilized to assess personal characteristics, ages, perception variables, and screening behavior. The statistical significance level was set at the same level for all calculation ( p ≤ 0.05).

In their result, they found (a) on a 12-point scale pertaining to knowledge about prostate cancer, the respondents recorded a mean score of 4.97 ( SEM 0.15 ), a well below average score; (b) for aggregate perception variables measured on a 30-point scale, the mean score was 17.65 ( SEM 0.18 ); and (c) for perception sub-variables such as perceived susceptibility and seriousness of prostate cancer, measured on a 15-point and 12-point scale, respectively, the mean scores were 8.85 ( SEM 0.14 ) and 6.218 ( SEM 0.09 ), respectively. However, perception of the benefits of screening, measured on a three- point scale, recorded a mean score of 2.59 ( SEM 0.03 ), and screening behavior variables, measured on an aggregated 11-point scale, recorded a mean score of 2.40 ( SEM 0.071 ).

The researchers concluded that in order to stimulate regular screening among men, there should be an aggressive health promotion intervention designed to increase awareness and to correct impressions about prostate cancer in the community. Importantly, the outcome of such screening would guide management of conditions throughout life, including the decision-making process, in which the individual would be an important part. The study recommends more awareness program in the community.

Karayurt and Dramali (2007) conducted a quantitative study to adapt the

Champion’s Revised Health Belief Model Scale (CRHBMS) for Turkish women and to

56 examine select socio-demographic variables associated with breast self-examination

(BSE). The study utilized a purposive sample of 430 women living in a health facility in

West Turkey. Of the sample ( N = 430), the age ranged from 20 to 60 years, with a mean of 39.7 years ( SD = 11.3). Seventy-nine percent ( n = 338) of the women were married and 21% ( n = 92) were single.

The CRHBMS went through the vigorous process of translation to Turkish, validated by professional judges, and then tested for reliability. Internal consistent reliability, construct validity, and predictive validity were tested among Turkish women.

The Cronbach’s alpha for each subscale ranged from .58 to .89, establishing internal consistency reliability. The obtained reliability coefficients of this study were similar to those of the original scale. However, the obtained coefficients were lower but acceptable for susceptibility and barrier subscales (.58 and .68, respectively).

The demographic results indicated that 49.5% ( n = 213) of the women performed

BSE at least once, but 50.5% ( n = 217) of the women never performed BSE in the last year. Of all women who performed BSE, 88% were married, 12% single, 58% high school and university graduates, 42% primary and secondary school graduates, 39% employed, and 61% unemployed. However, 94% of the women practicing BSE did not have a family history of breast cancer, but 6% had a family history of breast cancer and

2% had a history of breast cancer themselves. The results of the chi-square analyses revealed a significant relation between the frequency of BSE practice and education level

(X² = 38.50, P < 0 .05 ), family history of breast cancer ( X² = 7.65, P < 0 .05 ), and former training about breast cancer and BSE ( X² = 56.01, P < .001 ). In conclusion, the authors believed that understanding women’s beliefs about breast cancer and BSE can enable

57 nurses and other health care providers to design and offer appropriate health education programs for early detection of breast cancer. They also found the CRHBMS can be effective when used to test the effectiveness of intervention strategies. They recommend that health care providers be more familiar with the health belief of the patients in order to provide care accordingly.

Kleier (2004) conducted a qualitative ethnographic study guided by the Health

Belief Model (HBM). The purpose of that study was to investigate the knowledge and perceptions of Jamaican and Haitian men about prostate cancer. A total of 10 men between the ages of 45-74 were selected from each ethnicity for in-depth interviews.

Ethnographic accounts were collected for the purpose of discovering concepts and relationships in raw data and reorganizing them into themes.

The themes were organized by cohorts of the studied population and constructs of HBM. For perceived susceptibility, over sexually active as a factor was a common theme from the Jamaican cohort. As for the Haitian cohort, greasy diet as a factor was the common theme. As perceived barriers, both cohorts indicated embarrassment and discomfort of the DRE as a factor. The results indicated that Haitian men were less knowledgeable on the issue than Jamaican men; thus, they were less likely to participate in prostate cancer screening. Most importantly, the results also captured the difference in culture and how it was a major contributing factor to the results. The researcher also suggested that language might have been a barrier. Therefore, educational materials must also be in Haitian Creole in order to address this issue.

The studies in this section mostly indicate the lack of knowledge as a major barrier to prostate cancer screening. It is only logical to refrain from taking part in an

58 unknown activity regardless of its benefits. Knowledge plays a major role in determining how a person will behave regarding seeking health care assistance. Let it be noted that every population is different, and culture plays a major role in how knowledge is received

(Purnell & Paulanka, 2003). Hence, knowledge must be disseminated accordingly. Lack of knowledge of prostate cancer is found to be greater among African-American men and

African-Caribbean men. Given that educational materials are usually in written form,

Haitian men might be affected even more due to the high illiteracy rate in the Haitian population. The studies in this section focused on knowledge as a barrier to prostate cancer screening, but none of them actually examined the intention of Haitian men with regards to prostate cancer screening.

The health belief model (HBM) was originally created to help explain and predict health behavior. It originated in response to widespread failure of tuberculosis screening program. The authors of the model wanted to better understand what would make people behave a certain way regarding their health. Since the HBM’s creation, it has been modified and adapted for several health promotion and educational studies. Multiple studies using the HBM as a framework were reviewed, but only Kleier’s study addressed prostate cancer screening with regards to Haitian-American men. However, none of these studies addressed the perception of Haitian men living in Haiti and their intent to screen for prostate cancer. This particular study aimed to identify any predictive relationship between the select HBM constructs (perceived susceptibility, perceived benefits, and perceived barriers) and the intent of Haitian men to participate in prostate cancer screening. Additionally, it evaluated differences between select demographic

59 variables (age, level of education, marital status, religion, and family history) with

Haitian men’s intention regarding prostate cancer screening.

Factors Influencing Healthcare Seeking Behaviors

Influencing factors play a major role in people’s everyday behaviors. Such factors may be an individual’s educational level, economic status, ethnicity, marital status, or religion. Hence, it must be noted that health-seeking behaviors are bound to be influenced by many factors including these above-mentioned modifying factors.

Furthermore, the influencing process is not limited to just one originating factor, perhaps a combination or a grouping of many factors. In this section, the collection of these studies identified some of the factors influencing health care seeking behaviors.

Allen et al. (2013) conducted a qualitative study addressing the health beliefs, attitudes and service utilization among Haitians in the Boston metropolitan area. They believed that understanding the factors that influence health beliefs, attitudes, and service use among Haitians in the United States is increasingly important for this growing population. The focus of this exploratory study was to examine the factors related to cancer screening and utilization of health services among Haitians in Boston. The data were collected from interviews with 42 key informants and 9 focus groups (n = 78).

They described a key informant as someone who is very knowledgeable about the research topic and is able to verbalize the perception of the community with regard to the research topic. The initial key informants were health care providers, religious/faith leaders, business owners, media representatives, and civic organization leaders. The recruitment of the participants was done through a snowball sampling whereas a

60 participant would recommend another participant. The study was approved by the

Institutional Review Board at the Harvard School of Public Health.

The data analysis was conducted in line with grounded theory through constant comparative methods. The researchers sought to identify salient constructs as they transpired organically from discussions with and among community members. The themes from the data were organized into three categories: (a) community priorities, (b) barriers to service access and utilization, and (c) suggested solutions to impediments.

The results revealed that Haitians experience unique barriers to health services. These include language barriers, unfamiliarity with preventive care, confidentiality concerns, mistrust and stigma concerning Western medicine, and a preference for natural remedies.

Therefore, it is suggested that the Haitian population could benefit from health system navigation assistance, especially to help curve the avoidance of seeking treatment due to health care costs. The study also suggested the need for a comprehensive program to be highlighted, rather than disease-focused programs, to decrease stigma and increase outreach. The study indicated that the best route to disseminate health information to this population was through faith-based organizations, social service agencies, and the Haitian media. The authors recommended that health care providers consider these suggestions when working with the Haitian population.

DeRigne, Choi, Barsky, and Albertini (2012) conducted a qualitative exploratory study addressing the met and unmet healthcare needs of Haitian-Americans living with

HIV/AIDS. The motivation that triggered this study was due to the authors’ observation of the Haitian-American community being overrepresented among groups affected by

HIV/AIDS and yet remaining underserved in health care and social services. Data were

61 collected from a sample of 150 individual participants who were infected with or affected by HIV/AIDS from the Haitian community in Broward County, Florida. In addition, two focus groups of 8-10 health and human services professionals servicing the Haitian community were ascertained. The researchers recruited participants through a participatory action approach and snowball sampling. The interviews were conducted through open-ended and semi-structured protocols developed by the researchers. The interviews covered the following topic areas: (a) general experiences with health care in

Broward; (b) experiences (personally, within family, or among friends) with HIV/AIDS;

(c) experiences with health care services for people with HIV/AIDS; and (d) suggestions for improving health care services for people in the Haitian community with HIV/AIDS.

After the interviews, the researchers started data analysis by reviewing each interview in detail and by categorizing themes related to the goals of this research. The themes were categorized into “met and unmet needs.” A second-level analysis of themes across different interviews was conducted. After the second-level analysis, the researchers identified common themes and flagged key quotations. Participants conveyed a range of experiences with the health care systems, including both met and unmet health care needs. Among the central themes arising from the study were bureaucracy of the health care system, lack of resources among participants, misinformation and distrust, lack of privacy, and lack of culturally appropriate services.

One of the most persistent themes to occur from this study was the effect of stigma about having HIV/AIDS on the help-seeking behaviors of Haitians.

The findings suggested that it is imperative that culturally sensitive health care services are provided in order to reach out to the Haitian community living with

HIV/AIDS. There must be a comprehensive view among clinicians of the traditional and spiritual healing methods of the Haitian American community. Health care providers must show respect and provide confidentiality and privacy. Accessibility issues such as language barriers, difficulty navigating bureaucratic systems, transportation, housing, and family needs must be considered regarding this population. Hence, whenever possible,

Creole-speaking providers should be utilized to avoid any language barriers and misunderstandings. The researchers maintained that rendering culturally sensitive services will translate into greater access and more effective health care for the Haitian-

American population.

Khoury, Kaiser, Keys, Brewster, and Kohrt (2012) conducted a qualitative study to investigate whether explanatory models of mental illness invoking supernatural causation result in care-seeking from folk practitioners and resistance to biomedical treatment. The study was part of the compounding attention given to Haiti’s broken health care system from the national and international humanitarian response to Haiti’s devastating earthquake in January,2010. The broader focus of this study was to examine one key question through which mental health promotion can be informed: Are Vodou

(voodoo) understandings of mental illness an obstacle to seeking biomedical treatment in rural Haiti? In the study’s literature review, there is a general consensus that there are two Vodou illness representations in Haiti consisting of the natural and the supernatural.

According to this classification, it is generally thought by most that natural illnesses are more manageable through biomedical treatment whereas the supernatural requires the assistance of Vodou practitioners.

The study took place in Haiti’s Central Plateau, a rural mountainous zone located in central Haiti. It is the country’s most impoverished region, which is also an indication of little or no access to health or human services in the country. The participants were selected through purposive sampling to represent a range of community leaders, traditional healers, religious leaders, and biomedical providers who worked in a variety of settings. Data collection was drawn from 31 semi-structured interviews, 10 focus group discussions, and four case studies. The focus groups varied in size, from seven to 14 people, and they were separated by gender. The participants’ composition was of 32 males and 23 females. Data analysis was conducted using a mixed-method ethnographic approach to examine treatment-seeking pathways for mental illness caused by supernatural possession. The data collection centered on knowledge, attitudes and beliefs, etiology, experiences, and resources available for mental illness in rural Haiti.

Despite the general belief of Haitian and non-Haitian health professionals that belief in Vodou is an obstacle to biomedical mental health treatment, the findings of the study indicate otherwise. The authors found that folk practitioners expressed a desire to collaborate with biomedical providers and often referred patients to hospitals. However, they also believe that the biomedical system is largely ineffective for treating mental health problems. The findings indicate that explanatory models rooted in Vodou ethnopsychology were not primary barriers to seeking psychiatric treatment. Instead, there were structural factors such as the insufficiency of treatment resources and deficiency of psychiatric training among health practitioners, which generated the utmost impediments to biomedical care for mental health concerns in rural Haiti. Hence, it is recommended that health practitioners in Haiti have access to better training concerning

64 mental health. Furthermore, the population needs to be aware of and educated on mental health to help promote treatment seeking behavior.

Vornarx (2011) conducted a qualitative anthropological research to examine

Vodou as a healthcare system. The study was grounded in a 16-month residency in the most rural area of Haiti gathering data from a variety of sources and sites. The researcher’s rationale for this study was drawn from the gap that exists in the literature and the misconception about the subject. The author maintains that although much has been written about Vodou, very little is known about how oungan (voodoo priests) care for the sick, the knowledge they use to cure and treat illnesses, and their practices for dealing with illness. Hence, the researcher’s objectives were to analyze (a) Vodou’s role within a medico-religious social landscape made up of different caregivers and therapeutic traditions, (b) the supervision and treatment provided by practitioners to those seeking care, and (c) how the knowledge, practices, and discourses of Vodou practitioners are mobilized in illness episodes.

The researcher conducted the study through an ethnographical approach gathering data through interviews and observation. He completed the study by being in the field with Vodou practitioners and living daily in the world of small farmers in rural Haiti. He visited various places where the ill go to be treated so that he could meet care-seekers and weave a web of relations that would enable him to follow them along their therapeutic itineraries. The researcher noted the stigmatization involving the subjects being studied.

Since it was magico-religious, the practices that interested the researcher were private and covert.

Data collection was carried out through individual and group interviews focusing on identifying different stages in people’s health-seeking process, gaining an in-depth knowledge of the practices used by Vodou practitioners, ascertaining their discourse on illness, grasping the dynamics and relationships between different therapists and obtaining information on the Haitian medico-religious landscape and the features of each treatment sector. The sample was purposive. A total of 39 individual interviews were conducted with 21 Vodou practitioners and the researcher met regularly with six of them.

To incorporate a broader view of the Haitian medico-religious landscape, over 20 interviews were conducted with other therapists from Creole medicine, biomedicine, and healing churches. Lastly, 20 other interviews were carried out with individuals well acquainted with Vodou (a drummer, a person who washes the dead, elders, assistants to

Vodou practitioners, graveyard keepers, and participants in Vodou rituals) helped to fill any gaps in the researcher’s understanding. All the data gathered during the research were analyzed using NVivo software.

The findings make a clear indication that Vodou’s connections to illness go beyond a care-giving dimension identified for most religions. On the contrary, it shows that illness management is at the heart of the form of Vodou practiced in the Haitian countryside where it is represented as a health care system grounded in a unique ontology. The researcher discussed how the religious and magical dimensions have drawn attention to the many extraordinary skills possessed by the Vodou practitioners who, in the end, focus on the various dimensions of existence, ways of living, and the sick person’s physical and social environment. Furthermore, this analysis of the interconnection of medicine and religion within Vodouism can help to inform healthcare

66 practices in the West. The researcher noted the importance of such consideration in treating Haitian immigrants but not limited to Haitian immigrants only. The results will serve as a guide for healthcare practitioners to help them identify (a) how illness is understood and what dimensions of life that meaning reveals and is tied to; (b) what sources of suffering an understanding of illness brings to light, what dimensions of life are affected by illness, and which ones need to be attended to in taking care of the person who is ill; (c) which caregivers are best able to offer assistance that is coherent with the person’s understanding of their problem and with what they consider meaningful (both in the causes and the manifestations of that problem).

When working with a specific population, it is clearly logical to acquire a certain understanding about the general culture of the population in question and then an understanding regarding the population’s perception of the problem at hand. A population’s culture is believed to shape the general health status of that population

(Purnell & Paulanka, 2003). Hence, missing such an important piece working with a specific culture only sets the work on an unsuccessful path. The articles reviewed in this section focused on factors that may have influenced the health seeking behavior of

Haitians. They all mentioned the importance of taking the Haitian culture into consideration. They pointed out the lack of access as a major contributing factor, which could be the result of poverty, lack of means to access health care, and also lack of resources in the community. Consequently, in areas where health care is readily accessible, the lack of resources in the community limits the exposure to existing health treatments that are available. They also pointed out that health education should not be disease focused, especially in the Haitian community due to stigmatization. HIV/AIDS

67 and cancer are greatly stigmatized in the Haitian community. Health care professionals should instead focus on the person, promoting respect, confidentiality, and trust in the healthcare system. In addition to the economic situation of the Haitian community, religious belief, whether it is in conventional religion or non-conventional religion, must be considered. The literature indicates that most of the time, the biomedical treatment may be working in conjunction with the spiritual belief. In contrast, research has found that lack of education, familiarity, and resources are usually the major barriers rather than the spiritual belief.

The studies in this section clearly discussed numerous factors that may be influential to Haitian health care seeking behavior. These factors continue to have a major contribution to the perception of Haitians regarding the biomedical health care system and their own integration with the system. Furthermore, these studies suggest that health care professionals be familiar with the variety of cultural factors that may impact their patients’ perception of the care being delivered. Health care professionals need to focus more on the patients themselves rather than the disease (Rahill and Rice 2010).

Nonetheless, these studies focused on factors influencing Haitian health-seeking behavior, but none of the studies address the intention of Haitian men with regard to prostate cancer screening . None of the studies attempt to explain why there is such a high mortality rate of prostate cancer in Haiti. This study investigated predictive relationships between the select HBM constructs (perceived susceptibility, perceived benefits, and perceived barriers) and the intent of Haitian men to participate in prostate cancer screening. Moreover, the study assessed for differences between select demographic variables (age, level of education, marital status, religion, and family

68 history) with Haitian men’s intention regarding prostate cancer screening. Subsequently, it might provide some clarification or further understanding about Haitian men regarding prostate cancer and prostate cancer screening.

Factors Influencing Prostate Cancer Screening Behavior

As mentioned in the previous section, behaviors are conditioned to influential factors. Prostate cancer screening affects men exclusively. However, the factors influencing men’s behavior regarding prostate cancer screening do not necessarily pertain to men only. For example, a spouse may be the key influential factor in a husband’s behavior, but this spouse may have been conditioned by other factors that would not have been a major concern to the husband. In this section, this group of studies focused on factors that may be influential in men’s behavior regarding prostate cancer screening.

Costa and Moura (2013) conducted a qualitative study by interviewing a sample of men over 40 years of age in Brazil seeking to find out the meaning that men attributed to prostate touch examination. The sample size was not mentioned nor was the specific qualitative design. However, the men interviewed were all part of a public institution of higher education situated in the southern part of the metropolis of Rio de Janeiro. Their data analysis was completed through a descriptive qualitative approach with field research. Participants were faced with semi-structured questions consistent with themes for later analysis. Nonetheless, no specific theme was listed in the article. They maintained the relevance of their research due to the high incidence of prostate cancer and male resistance to clinical examination for prostate cancer prevention. The underpinning idea is that early detection of prostate cancer will provide a greater chance for less aggressive treatment. These researchers also argued that early detection of

69 prostate cancer could reduce the high costs arising from the treatment of advanced-stage cancer or metastatic disease.

In their recommendation, Costa and Moura (2013) strongly support screening because prostate cancer is the second leading cause of death in the male population in

Brazil. They believe that it is essential that health policy is improved to aim at increasing early detection of prostate cancer. Consequently, mortality rates will be reduced. They recommended that nurses must be competent to understand the sociocultural factors that are involved in order to minimize the embarrassment and stigmatization related to the prostate digital rectal exam (DRE). Nurses must emphasize the importance of DRE’s health benefits and that the patient’s masculinity will not be affected.

Ferrante, Shaw, and Scott (2011) conducted a qualitative study by having in- depth interviews with 64 white men aged 50 years and over. The sample was purposively taken from men who were never screened for prostate cancer or who were screened with abnormal prostate specific antigen (PSA) in northern New Jersey. They used a grounded theory approach to analyze their data. No identified themes were reported in the article.

However, the study found that men who actively sought out screening did so because of family history or they had previous abnormal PSA tests. On the other hand, men who had never been screened before tended to avoid testing due to their low-risk perception due to lack of family history. These men also believed that healthy behavior could prevent prostate cancer.

Some other contributing factors that lead to low participation rates were fear of cancer, embarrassment over digital rectal exam, misunderstanding over the screening procedure, and suspicion over the benefits of screening. The study also discussed a lack

70 of communication between the men and their doctors regarding pros and cons of testing.

Hence, most men reported to have received their health information through lay media, friends, or family members. As recommended, more education is needed to counteract the myths regarding prostate cancer and prostate cancer screening. Health care providers need to initiate the educational process and take their patients’ culture into consideration.

Lehto, Song, Stein, and Coleman-Burns (2010) conducted a descriptive, cross- sectional study to identify social ecological factors that affect screening behaviors for prostate cancer in African American men and knowledge that could be integral to the design of culturally appropriate interventions. The study was guided by the social ecological perspective. The authors explained that the social ecological framework of health promotion and education emphasizes the roles of social, cultural, and institutional contexts and the dynamic interaction among person-environment factors within these contexts as important for understanding African American men’s behavioral outcomes.

This study was conducted using a convenience sample of 60 African American adult men. Participants were recruited from the large metropolitan Detroit area, primarily from churches. They completed a socio-demographic survey that elicited information about age, educational background, marital and family status, health and medication history, employment status, presence of insurance, and history of prostate cancer screening via

PSA; questions related to health values and health behaviors; a trust in providers’ survey; and a stress-coping survey.

All variables were examined through descriptive statistics. Variables such as age, marital status, education level, insurance status, and screening status were dichotomized to obtain proper values. Chi-square tests and one-way ANOVA were conducted to screen

71 the potential variables that were significantly related to the prostate cancer–screening behaviors. Lastly, logistic regression analyses were used to achieve the research aim using SPSS version 16.0. An alpha level of .05 was used for all statistical tests, and r was calculated as the effect size.

The results found that most of the men were 50 years old or older (M = 54.8 ±

10.13, range 38 to 79). About 63% were married, and the majority had at least some post- high school education. It was also indicated that 70% of the men were employed, and the majority (92%) had health insurance. Half of the participants reported health problems such as hypertension or arthritis. Compared to those who did not have prostate cancer screening, men who obtained screening were more likely to be married (χ2 = 3.95 , df = 1, p < .05 ), 50 years or older (χ2 = 21.93, df = 1, p < .00 ), and to have health insurance (χ2 =

6.49, df = 1 , p < .05 ). Education and employment status were not related to screening behaviors. Moreover, one-way ANOVA results showed that participants who had prostate cancer screening tended to report higher scores on both positive health values and behaviors questions, F = 3.18 , df = 1, p < .05, and F = 6.87, df = 1, p < .01, respectively. Trust in Physician and the John Henryism scales were not related to

African American men’s prostate cancer screening behaviors (F = 0.08, df = 1, p > .05, and F = 0.58, df = 1 , p > .05, respectively ).

Logistic regression analyses found that men who were 50 years and older and who had higher scores on the health values survey were more likely to have prostate cancer screening in the past year (age and health values, χ2 = 22.71, p < .000 ).

Specifically, the odds of men 50 years and older having obtained PSA screening were about 16 times higher than those younger than 50 years of age (odds ratio [OR] = 15.72,

95% confidence interval [CI] = 3.45 to 71.64 ). The odds of men having had PSA testing also increased by about 26% for those who had 1-unit increase in their health behaviors and values measure (OR = 1.26 , CI = 1.02 to 1.54 ). Although being married and having health insurance and higher scores on the Health Behaviors Questionnaire also seemed to increase the likelihood of African American men obtaining PSA screening in the previous year, such findings were statistically insignificant.

As hypothesized, the authors found that African American men were most likely to report having obtained the PSA screening if they were older than 50 years of age.

Moreover, older men with higher positive health value scores were more likely to have received prostate cancer screening. However, differing to the study expectations, screening behaviors were not influenced by marital status, education level, health insurance, stress coping, and provider trust. The study recommends that programs that promote prostate cancer awareness among African Americans not only must target younger adults but also could devote efforts to improve general health behaviors (e.g., smoking, alcohol use, balanced diet, and exercise).

Carter, Tippett, Anderson, and Tameru (2010) conducted a quantitative study to evaluate the impact of prostate cancer education on screening rates among African

American men in rural Black Belt counties in Alabama. The goal of the study was to promote screening behavior in African American men. The study followed a quasi- experimental three-phase design: (a) focus group, (b) education intervention, and (c) follow-up. The authors sought permission for the study from the Internal Review Board

(IRB) at the Tuskegee University. Convenience sampling was utilized to target African

American men 40 years of age and older and their spouses/significant others from two

Black Belt counties in Alabama. The intervention program is an education-based approach and was delivered in three phases: focus groups, education, and follow-up.

Each phase provided information on prostate cancer, prostate cancer screening, and the importance of early detection to participants.

A total of six focus groups were held in both Bullock County and Macon

County—three in each county. The groups were separated by gender and also led by a facilitator of the same gender. The six focus groups included a total of 74 participants.

Three months after the education session, a follow-up phone survey was conducted with each participant. The phone survey focused on (a) knowledge of prostate cancer, (b) increase in dialogue about prostate cancer, (c) actual screening behavior, (d) level of spousal support, and (e) importance of women having knowledge of prostate cancer.

All statistics were analyzed using SPSS. The demographic survey indicated that the majority of focus group participants were married couples (88%) with a high school diploma or less (53%). The majority of participants had some type of insurance (97%) with only 3% indicating they had no insurance coverage. While most participants indicated they did not know the symptoms associated with prostate cancer (61%), county comparisons indicated Bullock County (80%) participants had the greatest lack of knowledge of symptoms. However, Bullock County (62%) had higher rates of annual screening than Macon County (52%) participants. The majority of male participants indicated they have annual screening from their physicians; however, when asked to indicate which test they were given, 77% responded both, 3% had only the DRE, and

20% had only the PSA. Of the male focus group participants, 5% had been diagnosed with prostate cancer.

The researchers generated data from the education intervention from two instruments: the demographic survey and pre- and posttests. A sample of 467 men and women participated in the education sessions; more than 85% of participants (N = 405) successfully completed the demographic survey and the pre- and posttests. The majority of the participants were males (n = 239), and 63% of the total population completed high school and at least some college. Despite the similarity of the two counties, there were significant differences in screening for prostate cancer (ever). Bullock County residents

(39%) were less likely to have been screened than Macon County residents (61%). In addition, the majority (61%) of participants knew what prostate cancer was, but only few knew the symptoms associated with prostate cancer (39%). Of the participants, 51% had been screened for prostate cancer at some point in their lives; 33% specified that they had been screened within the previous 12 months. Of those respondents, neither identified

PSA or DRE as the test used to be screened. This correlates with a lack of knowledge regarding the type of test given to screen for prostate cancer. It also supports focus group discussions where participants confused prostate and colon cancer screening procedures.

As expected, there was a correlation between age and prostate cancer screening.

The chi-squared test shows there is a significant association between age and screening status (p = .009 ). About 64% of the age group 40–49 reported that they have never been screened, and the age group 70–78 was the most screened for prostate cancer. Pearson correlation analyses indicated a strong relationship between marital status, screening within the last 12 months, education, socio-economic status, and insurance status.

With regard to pre- and posttest comparisons, there was a significant change in knowledge in all but four areas: (a) incidence between Whites and Blacks, (b) symptoms

75 associated with prostate cancer, (c) tests used to screen for prostate cancer, and (d)

Medicare coverage of prostate cancer screening. Based upon the analysis of pre and posttests, the researchers found that the project successfully increased the knowledge and awareness level of participants concerning prostate cancer.

Table 1

Parameters of Pre- and Posttest, Paired t-Test (Carter et al., 2010, p. 102)

Hypothesized Difference = 0 Mean DF t- p-Value Diff. Value

Prostate cancer is the number one cause of cancer -0.04 390 -0.99 0.3229 deaths in African American men. A man’s chances of getting prostate cancer increase, 0.09 398 3.12 0.0019 as you get older. Prostate cancer incidence is higher in whites 0.13 394 4.27 <.0001 compared to blacks. Prostate cancer always shows symptoms 0.12 392 3.38 0.0008

African American men should get a health exam, 0.07 399 2.53 0.0117 which includes a digital rectal examination, starting at the age of 40 The Prostate Specific Antigen (PSA) is one of the 0.48 397 10.99 <.0001 blood test for prostate cancer.

The Digital Rectal Exam (DRE) is the finger test for 0.44 396 10.41 <.0001 prostate cancer. If prostate cancer is found early, the chances of 0.06 403 3.15 0.0017 survival are greater Prostate cancer affects sexual performance 0.39 401 8.97 <.0001 One out of six African American men have a chance -0.02 396 -0.47 0.6414 of dying from prostate cancer.

There are two stages of prostate cancer, benign and 0.15 370 3.18 0.0016 malignant. Prostate cancer is an old man’s disease. 0.08 378 2.84 0.0048

More men die with prostate cancer than from prostate 0.54 376 10.86 <.0001 cancer. Prostate cancer treatment may cause impotence and 0.51 363 10.39 <.0001 incontinence.

Medicare covers prostate cancer screening costs 0.68 374 13.50 <.0001

Kleier (2010) conducted a correlational, cross-sectional study, first, to examine if perceived susceptibility to prostate cancer was congruent with the objectively measured disease risk; second, to test the relationships of components of an integrated model consisting of perceived susceptibility and fear; and third, to examine these constructs for their predictive relationships to prostate cancer screening behaviors among Haitian-

American men. A convenience sample of 143 Haitian-American men was selected throughout Broward County, Florida. The author used an integrated model consisting of a construct from the health belief model and the extended parallel process model as the framework for the study. Bivariate correlational analysis using Pearson was carried out to assess her hypotheses. The author also utilized regression analysis to identify any predictive relationship between the variables.

The results exposed some compelling correlations that were not corresponding to some other findings. Essentially, the results partially sustained the integrated model in that perceived susceptibility was highly correlated to fear and screening behavior (p <

0.05). Unexpectedly, fear was found not to be predictive indicator of screening.

Moreover, perception of risk was found to be much lower than actual risk. No significant correlation between the subjective perception of susceptibility and the objectively measured estimate of susceptibility based on recognized risk factors was found (r =

0.04). Nevertheless, there was a significant and positive correlation between perceived

77 susceptibility to prostate cancer and fear of prostate cancer (r = 0.82, p < 0.01). The author concluded that Haitian-American men do not recognize their increased risk for prostate cancer, so they are less likely to seek screening for prostate cancer. The study recommends Haitian-American men to be educated on their risk in order for them to make an adequately informed decision regarding prostate cancer screening.

Talcott et al. (2007) conducted a descriptive cross-sectional study investigating attitudes of African American men toward diagnosis and treatment among newly diagnosed patients with prostate cancer (PC). They recruited the participants through the

North Carolina tumor registry. A sample of 207 African American and 348 White men was obtained. The survey contained questions related to “demographic and socioeconomic characteristics, access to care, health attitudes and beliefs, PC screening history, PC diagnosis, its treatment, comorbidity, current PC-related symptoms, sexual function, daily living activities, and relationship with physicians, support system, and family history. Bivariate chi-square (X²) analyses were conducted to assess differences between Caucasian and African American for all variables examined. They considered p ≤ .01 statistically significant. The study found that African American men were significantly less likely than Caucasian men to have had regular checkups (89% versus

96%), digital rectal exams (DREs) (86% versus 93%), and prostate-specific antigen

(PSA) tests (69% versus 91%) (All p < .01). For Caucasian men, the elevated PSA was more often ordered by the doctor as a routine screen (80.4% versus 70.7%, p < .01), whereas African American men more often reported they had requested the PSA (13.7% versus 6.7%, p <.01). African-American men were more often uninsured (8% versus 3%) and without private Medicare supplementary insurance (17% versus 32%) (Both p < .01).

The majority of men in both groups reported an abnormal PSA test as the first evidence of prostate cancer. African-American men more often reported urinary symptoms or benign prostate hypertrophy (BPH) than Caucasian men as the first indication (17.4% versus 9.8%, p < .01) and reported PSA less often (87.9% versus 81.2%, p <.05).

The results showed that African-American men had less access and utilization of the health care system. They were less educated but aware of their high risk for prostate cancer. The findings also included mistrust in general in their providers and the health care, and lack of opportunity to utilize and access care. Fear was also more of a factor among African-American men than their White counterparts. It was recommended that healthcare providers discuss prostate cancer screening more often with African American men and be familiar with hidden barriers that may cause a hindrance in their health seeking behavior.

Forrester-Anderson (2005) explored attitudes regarding prostate cancer screenings through grounded theory. Twelve focus groups ( n = 104) were conducted among African

American men 40 years of age or older, residing in three counties in the metropolitan area of Baltimore, Maryland. Prior to the discussions, a short demographic questionnaire related to age, marital status, education, insurance status, and prostate cancer screening information was given to each participant after completing their informed consent. The demographic characteristics of the sample were examined via descriptive statistics, and the focus group data were analyzed according to grounded theory methods of analysis.

The results concluded that the associated barriers to screening among African American men are limited knowledge pertaining to prostate cancer, lack of access to screening services, fear of a positive diagnosis, and embarrassment. Among attitudes that served as

79 barriers, mistrust or lack of overall confidence was duly noted, especially in the government. Those attitudes also included lack of confidence in the health care system/medical professionals, the possibility of having the disease, unwillingness to talk about sex-related health problems, and a belief that prostate cancer is related to sexual behavior.

In this section, studies were reviewed because their focus was on multiple factors that affect prostate cancer screening behavior. Among the many, attitude was seen as a major factor as well as fear. Costa and Moura (2013) advised about the stigmatization relating to the DRE in certain cultures. Ferrante and his colleagues (2011) found that older men were more disposed to prostate cancer screening, and family history of prostate cancer was a contributing factor. Some of the studies concluded that some of the barriers to prostate cancer screening were lack of health care access and mistrust in the health care system, especially among African-American (Forrester-Anderson, 2005; Talcott et al., 2007). A few of the studies found fear of cancer itself was a barrier to screening.

Although fear was highly correlated with susceptibility of prostate cancer, Kleier (2010) found that fear alone was not predictive of either ever been screened or planning to be screened. This section covered the many factors that could be attributed to Haitian men with regard to prostate cancer screening. However, none of the studies specifically focused on Haitian men in Haiti regarding their intention to screen for prostate cancer.

This specific study explored the predictive relationships between select HBM constructs

(perceived susceptibility, perceived benefits, and perceived barriers) with the intent of

Haitian men to participate in prostate cancer screening. The differences between select demographic variables (age, level of education, marital status, religion, and family

80 history) were also probed with regards to Haitian men’s intention regarding prostate cancer screening.

Prostate Cancer Research Focused on Caribbean-Born Men

The Caribbean ranks number one in the world regarding prostate cancer mortality rate (World Life Expectancy, n.d.). Yet, there is a substantial gap in the literature regarding research focus on the Caribbean as it relates to prostate cancer. This particular research focused on a sample of men from a Caribbean country; thus, a review of the literature focusing on Caribbean-born men was warranted. In this section, these studies explore issues of prostate cancer pertaining to Caribbean-born men.

Cobran et al. (2014) conducted a quantitative study to examine the perceptions of prostate cancer (CaP) fatalism and screening behavior between United States-born and

Caribbean-born Black males. The authors expressed that few studies have examined the differences between U.S.-born and Caribbean-born Black males relative to CaP.

Furthermore, limited studies have explored the association between CaP fatalism and screening behavior. Hence, the purpose of this study was to compare perceptions of CaP fatalism and predictors of CaP screening with Prostate Specific Antigen (PSA) testing between U.S.-born and Caribbean-born African-American males. In this study, the researchers posed two main questions: (a) What are the associations between nativity, perceptions of CaP fatalism, and CaP screening with PSA testing within the last year? and (b) What are the strongest predictors of PSA testing within the last year, and do these predictors vary by perceptions of CaP fatalism and nativity?

This study was guided by the Powe Fatalism Model (PFM). According to the

PFM, an individual will partake in cancer screening contingently on the likelihood of

81 intervening variables, such as knowledge of cancer, perceptions of cancer fatalism, and general demographic influences such as race, age, gender, education, and income. The study was approved by the Institutional Review Board at Howard University. Data were collected primarily in Miami-Dade, Broward, and Palm Beach counties in South Florida.

A sample of 211 Black men was recruited from senior centers, community/faith organizations, and health fairs. The Personal Integrative Model of Prostate Cancer

Disparity (PIPCaD) Survey and the Powe Fatalism Inventory were utilized as measures for the study.

The researchers conducted a thorough analysis of all the data involved in the study. All data were analyzed using the statistical package SPSS 19 (International

Business Machine Corp., Armonk, New York). The demographic characteristics were abridged in proportion and means. Cronbach’s alpha coefficient was used to calculate the reliability of the modified Powe Fatalism Inventory and the modified PIPCaD Survey.

CaP knowledge, acculturation, CaP fatalism, spirituality, and perceptions of CaP treatments scores were summed from the modified Powe Fatalism Inventory, and the modified PIPCaD Survey for each participant. In addition, independent sample t-tests were carried out to compare CaP knowledge scores, perception of CaP treatment and fatalism scores of U.S.-born and Caribbean-born African-American males. To further examine the statistically significant predictors of CaP screening with PSA testing within the last year between U.S.-born and Caribbean-born Black males, multivariate logistic regression models were constructed.

Of the 211 participants, 117 (56 %) were U.S.-born Black males and 94 (44 %) were Caribbean-born Black males. Caribbean-born Black males reported higher CaP

82 fatalism scores compared to U.S.-born Black males, 35.78 ( SD = 10.43) versus 32.30 ( SD

= 11.10), respectively, p < 0.05. Nonetheless, U.S.-born Black males reported higher spirituality, perception of CaP treatment, and knowledge scores (e.g. 13.38 ( SD = 2.65);

7.37 ( SD = 1.86); and 5.51 ( SD = 1.86), respectively, p < 0.05), compared to Caribbean- born Black males (e.g. 13.06 ( SD = 2.63); 7.11 ( SD = 1.50); 5.27 ( SD = 2.01), respectively, p < 0.05).

The authors conducted a multivariate logistic regression to evaluate the adjusted predictors of CaP screening with PSA testing. The results found that age, education, spirituality, access to public or private health insurance, and doctors’ recommendation of

CaP screening with PSA testing were statistical significant predictors of CaP screening with PSA within the last year. Regarding significant predictors, U.S.-born and

Caribbean-born Black males with low spirituality scores were less likely to screen for

CaP with PSA testing within the last year (OR = 0.17, 95 % CI = 0.06, 0.54, p<0.05) compared to males with high spirituality scores. Furthermore, when compared to U.S.- born and Caribbean-born Black males without a doctors’ recommendation of CaP screening with PSA testing, males with a doctors’ recommendation were more likely to screen for CaP with PSA testing within the last year ( OR = 14.76, 95 % CI = 4.59, 47.41, p < 0.05). However, nativity, acculturation, CaP fatalism, and CaP knowledge were not statistically significant in predicting of CaP screening with PSA testing within the last year ( OR = 0.80, 95 % CI = 0.26, 2.48, p = 0.70; OR = 1.27, 95 % CI = 0.46, 3.49; OR =

1.37, 95 % CI = 0.48, 3.91; OR = 0.59, 95 % CI = 0.20, 1.79, p < 0.05 respectively).

Finally, the authors discussed possible limitations to the study. They pointed out that using a cross-sectional research design to investigate the main outcome may limit the

83 research results to reflect causation. In addition, the sample may not be representative of

U.S.-born and Caribbean-born Black males in South Florida due to the use of a non- probability sampling process. The study recommends that health care providers increase their education of prostate cancer screening to their patient and make proper recommendation when needed.

Ng et al. (2013) conducted a qualitative study to investigate the factors that influence prostate cancer healthcare practices in Barbados, West Indies. The purpose of the study was (a) to identify individual, socio-cultural, and system-level variables that promote or impede pathways to prostate cancer screening and care among the country’s residents; and (b) to assess the knowledge, attitudes and practices of African-Barbadian men regarding prostate cancer. The researchers sought and obtained approval for this study from the Barbados Ministry of Health and Stony Brook University Institutional

Review Boards (IRBs). This study utilized a community-based participatory research

(CBPR) model. The authors reported that CBPR is known as a scientiﬁc inquiry conducted in communities in which all members within the community may take full part in participation in each phase of the work (conception - design - conduct analysis - interpretation - conclusions - communication of results).

Data were collected through in-depth interviews of 30 community members. All interviews were carried out by one interviewer, and each interview lasted approximately

30-45 minutes. The interviews took place at the Winston Scott Polyclinic in Barbados or at the business ofﬁce of the community member. The interviews were then transcribed and coded to categorize common topics and then themes. Factors of interest included: (a) knowledge about prostate cancer and early detection, (b) perspectives about access to

84 health care and health education, (c) fears about prostate cancer, (d) beliefs about disease, and (e) personal experience with prostate cancer.

The study found that many of the themes observed as barriers to prostate care in

Barbados were similar to those described for African-American men. These themes included fear of cancer, fear and discomfort with the DRE, perceived threats to their manhood, concerns about privacy, embarrassment, distrust of the medical community, discontinuity of care, competing concerns (e.g., work, family), and inadequate or ineffective dissemination of information. One interesting and unexpected finding is that knowledge was more of an issue for African-American men. Another interesting factor was the lack of access to health care; it was not the case for African-Barbadian men likely due to the national health care system in Barbados that provides standard care to all residents. Overall, the results of this study indicated that gender-speciﬁc perspectives and cultural beliefs were the dominant factors in determining whether African-Barbadian men seek care.

McCree-Hale, Hale, Rutley, Aung, and Jolly (2012) conducted a quantitative study to evaluate the impact of a theory-based health education intervention on awareness of prostate cancer and intention to screen among men in Western Jamaica. This was a cross-sectional study with a pretest/posttest design. The study was conducted at the

Cornwall Regional Hospital and select, non-randomized health centers in the parish of St

James, Jamaica. The sample was drawn conveniently from patients who came to the hospital and the centers. Men ages 40 years and older were eligible to take part in the study. They were approached in the waiting area as they awaited to be seen by a practitioner. The protocol for this study was approved by the Institutional Review Board

85 of the University of Alabama at Birmingham, the Advisory Panel of Ethics and Medico-

Legal Affairs in the Ministry of Health, Jamaica and the Western Regional Health

Authority. This study was guided by the transtheoretical model [TTM] and the health belief model.

All participants completed a 25-item interviewer-administered pretest questionnaire. The questionnaire was evaluated and considered culturally appropriate and easy to understand. The topics of the questionnaire were related to socio-demographic information, which included age, marital status, educational attainment, income, religious affiliation, and race. Some specific questions were about attitude, knowledge, perceptions, and behaviors regarding prostate cancer risk factors, symptoms, and screenings. The posttest was given to participants immediately following the computer- based educational intervention. Questions on the posttest assessed participants’ knowledge of prostate cancer, screening tests, risk factors, and intention to screen. The original sample consisted of 207 participants, of which 13 completed the pretest but failed to complete the posttest. Furthermore, six participants completed the posttest but did not complete the pretest. These 19 participants were excluded from the data analysis.

The final sample was modified to exclude these 19 participants ( n = 188).

The descriptive statistics of the sample showed that the participants’ age ranged from 40 to 89 years with a mean age of 58.7 years. The majority of the men were aged

50–59 years (35.6%), married (48.4%), with a primary level education (46.0%), and working as manual laborers (56.2%). Furthermore, the majority of the men (98%) self- identified as Black; 17% reported having a father, brother, or son with prostate cancer. In addition, about a third of the men (36.3%) reported to have been screened for prostate

86 cancer. Regarding the pretest and posttest results, the p-values of the McNemar’s test indicate statistically significant differences in the percentage of correct responses between the pre-test and post-test ( p < 0.05). In the pretest analysis, the knowledge of risk factors was relatively high as compared to knowledge of prostate cancer screening.

Fifty-one percent of the sample knew about the recommendation for prostate cancer screening for men over age 40. Of the most common used screening tests, 24.5% indicated to have had knowledge of DRE, 9.8% knew of PSA, and 2.7% knew of the ultrasound.

Regarding symptoms, the majority (68.4%) identified correctly that a weak urine flow, blood in the urine, pain or burning urination, and lower back pain as symptoms of prostate cancer. About three-fourths of the sample correctly identified a family history of prostate cancer, being 40 years old (76.6%), and a high fat diet (74.0%) as risk factors.

Approximately, half (54.7%) of the sample identified correctly that men of African descent were also at a greater risk than their counterparts. In general, there were statistically significant increases in the percentage of correct responses between the pretest and posttest. The improvement that stood out was related to the knowledge of prostate cancer screening tests. The percentage of knowledge of the recommendation increased from 51.0 to 93.3% ( p < 0.0001). Knowledge of DRE, ultrasound, and PSA increased by 57.6, 60.3 and 73.4 percentage points, respectively ( p < 0.0001).

Knowledge of prostate cancer symptoms increased by about 21 and 26 percentage points and knowledge of risk factors increased between 9 and 28 percentage points. The researchers found that the theory-based patient education program was significant in educating and improving knowledge regarding screening behaviors. Therefore, they

87 maintain that it can be replicated to promote awareness of prostate cancer and inform screening methods including potential risks associated with screening behaviors.

Kleier (2010) conducted a correlational, cross-sectional study using an integrated model comprising of a construct from the health belief model and the extended parallel process model as the framework. This author wanted to explore if perceived susceptibility to prostate cancer was consistent with the objectively measured disease risk. In addition, she also wanted to test the relationships of components of an integrated model consisting of perceived susceptibility and fear. Furthermore, her other objective for this study was to investigate these constructs for their predictive relationships to prostate cancer screening behaviors among Haitian-American men. The author gathered

143 Haitian-American men in Broward County, Florida via convenience sampling.

Besides the demographic questionnaire, the author utilized three previously developed instruments to measure the variables being studied. These instruments had been tested for psychometric properties when used with Haitian-American men regarding prostate cancer. They were also modified to account for language and content with regards to Haitian-American men. These instruments were: (a) Kleier prostate cancer fear scale, an 8-item scale with responses scored on a 4-point Likert scale where 1 indicated strongly disagree and 4 indicated strongly agree ; (b) Kleier perceived susceptibility to prostate cancer scale, a 3-item scale with responses scored on a 4-point

Likert scale where 1 indicated strongly disagree and 4 indicated strongly agree ; and (c)

Your Disease Risk for Prostate Cancer index, an online questionnaire scored on a 7-point scale where a 7 score would be considered above average in risk for developing prostate cancer, a score of 4 was considered to be an average risk, and a score of 1 indicated the

88 risk was below the average. Bivariate correlational analysis using Pearson was carried out to assess the studies hypotheses. The author also utilized regression analysis to identify any predictive relationship between the variables.

From the sample, the majority of the participants (n = 80 , 55.93%) reported never having a prostate examination, while 63 (44.1%) indicated they had undergone a prostate examination at some time. Of these 63 participants, 50 (79.4%) reported the length of time since their last examination; 43 (86%) conveyed having been examined within the past five years; however, seven participants exceeded the 5-year mark and 3 reported that it had been at least 10 years since their last examination ( M = 2.78, SD = 2.57).

Furthermore, 82 participants (57.3%) reported that they had no plan for prostate screening in the future.

In the results, the measurement of disease risk based on identified risk factors provides clear evidence that the majority of the participants’ responses reflect an above average to a very much above average risk ( n = 127, 92.7%) to prostate cancer. The study also found that there was no significant correlation between the subjective perception of susceptibility to prostate cancer and the objectively measured estimate of susceptibility based on recognized risk factors (r = 0.04). However, there was a significant and positive correlation between perceived susceptibility to prostate cancer and fear of prostate cancer (r = 0.82, p < 0.01). In the regression analysis, only perceived susceptibility to prostate cancer was significantly related to participation in prostate screening behavior (p < 0.05).

The findings partially supported the integrated model in that perceived susceptibility was highly correlated to fear and screening behavior. Perception of risk

89 was much lower than actual risk. Fear was not predictive of screening. Kleier concluded that Haitian-American men do not recognize their increased risk for prostate cancer, so they are less likely to seek screening. Haitian-American men must be educated on their true risk so they are adequately equipped to make an informed decision regarding screening.

Consedine et al. (2007) conducted a quantitative study to examine the relevance of emotional and cognitive characteristics to digital rectal exam (DRE) and prostate specific antigen (PSA) screening among 180 U.S.-born African American, U.S.-born

European American, and immigrant Jamaican men. The study was approved by the Long

Island University Institutional Review Board. A convenience sample of 180 men was recruited from various places through local newspapers, community postings, and contacts, as well as at health fairs and senior centers. Of the 180 participants, 60 of them were self-identified as belonging to each of these three ethnic groups: U.S.-born

European American, U.S.-born African American, and Jamaican immigrant. The researchers clarified that because prostate cancer risk is greater at younger ages among minority men, they recruited African American and Jamaican participants in the 40- to

70-year age bracket and European American participants in the 50- to 70-year age bracket.

The survey consisted of a few measures to gather up the data needed for the study.

The first measure was a background questionnaire to elicit information regarding self- reported ethnic group membership, age, household income, and education. The second measure was prostate cancer screening behavior . This questionnaire comprised of questions pertaining to prostate cancer screening behaviors, specifically the number of

DREs and PSA tests in the past 10 years. The third measure was prostate cancer knowledge . This questionnaire was developed based on prior work and expanded in consultation with expert oncologists and urologists. It is a 50-item scale that assessed knowledge in six domains of prostate cancer knowledge—anatomy, screening, risk, warning signs, treatment, and general. The last measure of the survey is prostate cancer attitudes . This questionnaire is a 30-item measure that assessed attitudes toward prostate cancer and prostate cancer screening. The survey took a total of 90 minutes to complete.

The demographics data was calculated through MANOVA. An Ethnicity × Age

MANOVA on income and education revealed a significant effect for ethnicity (Wilks’s λ

= 9.25 , p < .01 , η²p = .10), on both income, F (2, 174) = 11.98, p <. 01, η²p = .12, and education, F (2,174) = 9.01, p < .01, η²p = .09. Games-Howell post hoc tests showed that U.S.-born African Americans reported lower income than did either U.S.-born

European Americans or Jamaicans, and both U.S.-born African Americans and Jamaicans reported fewer years of education than did U.S.-born European Americans. However, an

Ethnicity × Age MANOVA on PSA and DRE frequency revealed no ethnic effects and, instead, a significant age effect (Wilks’s λ = 11.36 , p < .01 , η²p = .12), for both PSA, F

(1, 174) = 22.58, p < .01, η²p = .12, and DRE frequency , F (1, 174) =10.08, p < .01, η²p =

.06. Consistent with prior work, older men reported more PSA tests and DREs irrespective of ethnicity.

The next result that the researchers discussed was between ethnic and age differences in the six knowledge subscales. A MANOVA with age and ethnicity as between-subject factors and income and education as covariates was conducted; education was dichotomized and added to a MANOVA with ethnicity, age, and education

91 as grouping factors and the six knowledge measures as dependent variables. Ethnicity was found to be significant again (Wilks’s λ = 3.21, p < .01 , η²p = .11), as was education

(Wilks’s λ = 2.16 , p <.05 , η²p = .07), and the interaction between ethnicity and education

(Wilks’s λ = 2.54 , p < .01 , η²p =.09). There were no significant differences in knowledge as a function of age. Follow-up univariate tests showed that ethnicity had significant effects for anatomy, F (2, 168) = 5.22, p < .01, η²p = .06; risk, F (2, 168) = 6.77, η²p =

.08; screening, F (2,168) = 3.32 , p < .05 , η²p = .04; and warning signs. Education was significant for risk, F (1, 168) =9.64, p < .01, η²p = .05; screening, F (1, 168) = 3.98 , p <

.05, η²p = .02; and general cancer knowledge subscale scores, F (1, 168) = 5.80 , p < .01,

η²p = .03. As is typical, individuals that are more educated had superior knowledge. In addition, ethnicity interacted with education such that although more educated individuals generally had better knowledge, specific knowledge regarding anatomy, F (2,

168) = 5.64, p < .01 , η²p =.06, and treatment, F (2, 168) = 4.77, p < .01 , η²p =.04, was poorer among more educated Jamaicans.

With regard to attitude, ethnicity was again significant (Wilks’s λ = 3.28, p < .01,

η²p = .06) as were education (Wilks’s λ = 4.73, p < .01 , η²p = .08) and income (Wilks’s λ

= 5.75 , p <.01 , η²p = .10); age was marginal (Wilks’s λ = 2.22 , p = .09, η²p = .04), with older age being weakly associated with reduced fear. Inspection of the univariate effects showed that greater income was associated with less screening fear, F(1, 165) = 16.93, p

< .01 , η²p = .09; greater education was associated with greater belief in the efficacy of treatment, F(1, 165) = 11.96, p < .01 , η²p =.07; and greater age was associated with less fear, F(1, 165) = 4.32 , p < .05 , η²p = .03. U.S.-born European Americans reported less fear of screening than did U.S.-born African Americans and were marginally ( p = .08)

92 less fearful than were Jamaican men. Interestingly, immigrant Jamaican men reported significantly greater emasculation concern than did both U.S.-born African American and

U.S.-born European American men.

Finally, the authors surveyed whether aggregate knowledge variables and attitudinal variables predicted PSA and DRE screening, whether they did so above the impact of demographic variables, and whether they did so equally for the two different tests. It appeared that for PSA testing, fear and efficacy interacted such that fear was strongly related to lower screening but only when efficacy was low. Finally, there was a marginally significant three-way interaction between fear, knowledge, and type of test,

Wilks’s λ = 3.01, p = .085 , η²p = .02. The interaction plot suggested that although greater knowledge made no difference to DRE rates, knowledge and fear interacted in the prediction of PSA such that being afraid did not affect the screening of individuals with high knowledge.

The study revealed as predicted that U.S.-born African American and Jamaican men had significantly poorer knowledge of prostate cancer in a number of domains and reported considerably more fear of prostate cancer screening processes than the U.S.-born

European men. However, there were no ethnic differences in treatment efficacy beliefs.

Furthermore, as expected, greater fear was negatively associated with screening frequency, and there were several interactions consistent with the study’s expectations that fear would be differentially relevant to DRE frequency and that greater efficacy beliefs or greater knowledge might protect men from the effects of screening-related anxiety.

This section of the literature review was designated to review prostate cancer studies addressing Black men of the Caribbean and their cultural influence with regard to prostate cancer screening. Considering the beliefs, cultural inﬂuences, barriers, and other factors that might inspire the decisions made by other Caribbean Black men regarding their personal health may be beneficial in generating interventions for Haitian men in

Haiti. Several of the studies suggested that knowledge was a major factor, and that educational information must be disseminated directly to groups or areas where men are often present. Some the locations mentioned were work, sport arenas, churches, and barbershops. Another suggestion is that the information be given, besides a healthcare provider, by champions—individuals who are familiar and respected in the community.

A prostate cancer survivor is an ideal champion.

Furthermore, all of the studies in this section indicated the commonality that is found in barriers to prostate cancer screening between African-American and African-

Caribbean men. Barriers included fear of cancer, the embarrassment involved the DRE, the threat to an individual’s manhood, and mistrust of the medical system. These factors are all too familiar across the Caribbean and in the United States. Although these factors can be attributed to Haitian men, none of the studies specifically addressed the intention of Haitian men regarding prostate cancer screening.

Chapter Summary

The literature comprised of a vast amount of research covering multiple topics regarding prostate cancer. The topics ranged from low risk to high risk addressing prostate cancer via diverse methods concerning different races and ethnicities. In this chapter, the literature was subdivided to address the purpose of this study. The literature

94 was categorized under these heading: Studies Using Health Belief Model as Framework,

Factors Influencing Health Care Seeking Behaviors, Factors Influencing Prostate

Cancer Screening, and Prostate Cancer Research Focusing on Caribbean-born Black

Men. The literature is immense regarding prostate cancer, but a minuscule amount of research focuses on Haitian men. The few research studies found concerning Haitian men clearly indicate that Haitian men’s perception and lack of knowledge were the major contributing factors to their low participation rate in prostate cancer screening. However, none of the studies addresses the intention of Haitian men regarding prostate cancer screening. It is imperative that more research is conducted pertaining to Haitian men in order to fill in the gap that currently exists in the literature. This proposed study will address this gap in the literature.

CHAPTER THREE

METHODS

The purpose of this study was to determine which of these selected constructs of the Health Belief Model (perceived susceptibility, perceived benefits, and perceived barriers) are predictors to the intent of Haitian men regarding prostate cancer screening.

The study also explored the relative contributions of these selected demographic variables (age, level of education, marital status, religion, and family history) to Haitian men’s intention regarding prostate cancer screening. This study took the path of a correlational, predictive quantitative approach. Quantitative research methods may be defined as the systematic empirical investigation of phenomena through statistical or numerical data. The purpose of quantitative research is to develop and engage in mathematical models, theories, and hypotheses pertaining to phenomena (Polit & Beck,

2012).

The quantitative approach is influenced by the philosophy of positivism. In the positivist’s view, the primary purpose of science is to predict, explain, and control occurrences. The Health Belief Model (HBM) is well aligned with such a view of science. Furthermore, it seeks to explain and predict health behavior. Hence, the HBM served as the framework for this study. In addition, the Purnell Model for Cultural

Competence served as a secondary lens through which this study was conducted to account for the lack of cultural aspect of the HBM. However, its constructs were not tested in this study. This study investigated the predictive relationship of these three independent variables: perceived susceptibility (perceived threat), perceived benefits, and perceived barriers with the intent of Haitian men living in Haiti (the dependent variable)

96 regarding prostate cancer screening. Moreover, this study also considered select demographic variables (age, level of education, marital status, religion, and family history) that may inspire the intent of Haitian men regarding prostate cancer screening.

Among these select demographic variables, age was examined as a predictor as well.

Consequently, this study planned its data analysis to accommodate four predictors.

In terms of use of instruments, this study applied a modified version of the

Champion Health Belief Model Scale for breast cancer in accommodation to prostate cancer to operationalize the relationship of the select HBM constructs to the intent of

Haitian men. In addition, a demographic questionnaire including items addressing the intent to participate in prostate cancer screening was administered. The purpose of the demographic questionnaire was to, first, describe the characteristic of the sample population; second, help determine potential associated factors with the select HBM constructs; and third, help identify the relationship between the select HBM constructs and the intent to prostate cancer screening. This chapter will address every component necessary to present the methods of the study as a whole. The content of this chapter will be disseminated under these headings as follows: overview of the design; hypotheses studied; setting; sample; inclusion criteria; exclusion criteria; ethical considerations/protection of human subjects; recruitment procedure; data collection procedure; instruments/measures; data analysis plan; and chapter summary.

Overview of the Design

Quantitative Inquiry

The high incidence and mortality rate of prostate cancer in Haiti was the phenomenon of interest of this study. Determining predictors of Haitian men’s intention

97 regarding prostate cancer screening was the underlying task of this study. Hence, to better determine such a relationship or correlation among the studied variables and make predictions accordingly, this study used a descriptive correlational, predictive cross- sectional design. Such a design is originated from the quantitative methodology.

The quantitative approach assumes knowledge comes from the physical world.

The general goal is to describe associations or correlations, relationships, explain cause and effect, and make general inferences (Kerlinger & Lee, 2000). The quantitative approach is considered as a pure scientific method. The researcher uses deductive reasoning to generate predictions that are tested in the real world (Polit & Beck, 2012).

Quantitative research is usually conducted systematically through a series of steps, using empirical data, striving for generalizability. There are four main types of designs in the quantitative approach: descriptive, correlational, causal-comparative/quasi-experimental, and experimental designs. The descriptive design simply seeks to describe the significance of identified variables; the correlational design seeks to delineate the relationship between two or more variables; the causal-comparative/quasi-experimental design seeks to determine cause and effect relationship among the variables; and the experimental design seeks to establish cause and effect among the variables (Creswell,

2003; Polit & Beck, 2012). For the purpose of this study, the descriptive correlational and cross-sectional designs were reviewed.

Descriptive Correlational and Cross-Sectional Design

Correlational research explores the interrelationship among variables of interest without the researcher’s intervention. Hence, the determined correlation is the relationship or association between two variables with the tendency for variation in one

98 variable to be related to variation of another (Polit & Beck, 2012). Such relationship can be examined between more than two variables using multiple regression analysis.

However, correlational studies have some limitations, among them is self-selection sample. In correlational studies, researchers work with pre-existing groups that were not formed at random. Furthermore, it is difficult to interpret the correlational findings that stem from behaviors, attitudes, and similar characteristics. In the real world, they are interrelated (Polit & Beck, 2012). The strength of correlational research is its efficiency in collecting a large amount of data about a phenomenon, the capability of making causal inferences, and is usually strong in realism (Polit & Beck, 2012).

A cross-sectional design involves the collection of data once the phenomenon under study is captured during a single period of data collection (Polit & Beck, 2012). It is appropriate for describing the status of a phenomenon or for describing relationships among phenomena at a fixed point in time. Cross-sectional design is often used to describe some feature of the population, such as prevalence of an illness, or it may support inferences of cause and effect (Levin, 2006). For example, a researcher may look at the correlation of a specific activity (alcohol consumption) with a specific disease

(liver cirrhosis). If the findings show a strong correlation, then a causal inference can be made of the alcohol consumption to the cirrhosis.

Choosing a descriptive correlational and cross-sectional design fits well with the purpose of the study. Correlational research determines correlation and allows for causal inferences. Cross-sectional design allows for data to be collected in one single period and also supports causal inferences. Predictive design involves the foretelling of a likelihood of something happening. It is the projection of a likelihood occurrence from a

99 known baseline. This study is using the HBM as a framework due to its predictive constructs. Accordingly, this study aims to determine predictive correlation between the selected HBM constructs and Haitian men’s intention regarding prostate cancer screening, and also seeks to discover possible causes for Haitian men’s low participation rate in prostate cancer screening. Understanding predictors to Haitian men’s intent regarding prostate cancer screening will help nurses and other health providers modifying their approach with Haitian men regarding prostate cancer screening.